Diagnostic & Intake

Main Point of Contact

Title

Phone *

Email *

Business Information

Business Name

Address *

Street Address

City

State

Postal code

Other Locations

HQ

Employee Information

Full Time

Part Time

W2

1099

Deduction Mode

Weekly
Biweekly
Semi Monthly
Monthly
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Section 125 *

Yes

No

Current Plan - Start Date

Current Plan - End Date

Current Plan Cost

$

Medical

Medical *

Yes

No

Medical Carrier

Number of Medical Plans

-
1
2
3
4
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Plan 1 - Deductible: Ind

$

Plan 1 - Deductible: Fam

$

Plan 1 - Co-insurance

$

Plan 1 - Max

$

Plan 2 - Deductible: Ind

$

Plan 2 - Deductible: Fam

$

Plan 2 - Co-insurance

$

Plan 2 - Max

$

Plan 3 - Deductible: Ind

$

Plan 3 - Deductible: Fam

$

Plan 3 - Co-insurance

$

Plan 3 - Max

$

Plan 4 - Deductible: Ind

$

Plan 4 - Deductible: Fam

$

Plan 4 - Co-insurance

$

Plan 4 - Max

$

STD

STD *

Yes

No

STD Elimination Period - Injury

STD Elimination Period - Illness

STD Benefit Duration

STD % of Income

STD Provider

STD Paid

Voluntary (EE)

Employer (ER)

LTD

LTD *

Yes

No

LTD Elimination Period - Injury

LTD Elimination Period - Illness

LTD Benefit Duration

LTD % of Income

LTD Provider

LTD Paid

Voluntary (EE)

Employer (ER)

Additional Coverages

Dental *

Yes

No

Dental Paid

Voluntary (EE)

Employer (ER)

Shared

Dental Provider

Vision *

Yes

No

Vision Paid

Voluntary (EE)

Employer (ER)

Shared

Vision Provider

Accident *

Yes

No

Accident Carrier

Cancer *

Yes

No

Cancer Carrier

Critical Illness *

Yes

No

Critical Illness Carrier

Hosp/Gap *

Yes

No

Hosp/Gap Carrier

Company Life/AD&D *

Yes

No

Company Life/AD&D Carrier

Company life/AD&D Coverage Amount

Voluntary Life Options?

How do the employees currently enroll/make changes to benefits?

Current benefit admin system? *

Target date for enrollment?

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