Company Information
Name of Company:   
Address:   
City, State  Zip:   
Contact:   
Phone:   
E-mail:   
Fax:   
Range of FT Employees:   
Actual no. of FT Employees:   
Hours Required:   
Range of PT Employees:   
Actual no. of PT Employees:   
Actual no. of Union Employees:   
 
Background Checks
Do you perform prescreen background checks?    Yes     No
Who is your provider?   
 
Drug Screening
Do you perform a drug screen on your employees?    Yes     No
Who is your provider?   
 
Medical Plan Information
What month does your health insurance plan renew?  

By what percentage did the cost of your medical plan increase last year?   
What strategies did you utilize last year to reduce your medical costs?   
Rank the following compliance issues from most difficult to keep up with to least difficult (1 = most difficult, 4 = least):    COBRA
   Cafeteria
   HIPAA
   FMLA
 
Payroll Software
Name of payroll software used:   
Are you satisfied with it?    Yes     No
 
HR Software
Name of HR software used   
Are you satisfied with it?    Yes     No
 
Full-Time Employee Requirements

What is the minimum requirement to have...
One week of vacation?   
Two weeks of vacation?   
Four weeks of vacation?   
 
Benefit Topics
Currently offered to...
% paid by employer
Review, add,
FT
PT
FT
PT
Current Carrier
request bids
this year?
Health Insurance
Y N
Y N
%
%
Y N
Dental Plan
Y N
Y N
%
%
Y N
Group Life Insurance
Y N
Y N
%
%
Y N
Short Term Disability
Y N
Y N
%
%
Y N
Long Term Disability
Y N
Y N
%
%
Y N
Vision Insurance
Y N
Y N
%
%
Y N
Family Legal Plan
Y N
Y N
%
%
Y N
Medical Gap Insurance
Y N
Y N
%
%
Y N
EE Benefit Statements
Y N
Y N
%
%
Y N
Section 125 Plan
Y N
Y N
%
%
Y N
Flex Spending Account
Y N
Y N
%
%
Y N
Medical Discount Plan
Y N
Y N
%
%
Y N
Retirement Plans
Y N
Y N
%
%
Y N
Health Reimbursement Arrangement (HRA)
Y N
Y N
%
%
Y N
Health Savings Account (HSA)
Y N
Y N
%
%
Y N
 
Special Questions
Is your company planning to install a HSA program this year?    yes     no
Would you like to receive additional information on HSA programs?    yes     no
What do you see as your most valuable employee benefit?   
What is the name of your benefit consultant/broker?   
What is the name of your retirement plan consultant?   

Notes/Comments: