Employer Information Request

Company Name: *

Address:

Contact

Contact Name: *

Title:

Phone Number: *

Email Address: *

Business Type:

Proprietorship

Partnership

Corporation

Fax Number:

How long has the company been operating?:

What is your current plan renewal date?:

What effective date do you want?:

Tax ID Number:

Do you currently have:

Insurance Selections:

Worker's Comp

A Payroll Company

Section 125 Plan

How Many Employees are on the Payroll?:

How Many are eligible for benefits?:

How Many employees are W2:

How Many employees are 1099:

What is the waiting period for new employees for benefits?:

1 Month, 2 Months, 3 Months....

Are you waivign the waiting period for the initial group?:

Yes

Hours

Nevada Statue states that employees must work at least 30 hours to be considered Full Time.

How many employees work full time?:

How many employees work part time?:

What hours do you currently consider to be full time?:

Pre-Existing Conditions:

Are you aware of any ongoing pre-existing conditions or pregnancies within your group (employees or dependents)? Please note them here.

Claims:

To the best of your knowledge, have there been any claims in excess of $10,000 in the last year? Please describe and give current conditions, if known.

Coverage

What is the employer contribution for employee coverage?: %

50 - 99 %

What is the employer contribution for dependents?: %

0-99%

Benefit Plans

Please check what benefits you currently (or plan to) offer.

Additional Benefits:

Are there any additional benefits you would like us to secure proposals for? Please list them here.

Current Plans

What do you like best about your current plan?:

What do you like least?:

What would you like to see on your new plan?:

McMillan and Associates

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