| 1) |
Please indicate the total number of employees, including yourself, who
are eligible for this group health insurance plan: [required] |
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(Selecting this answer will redirect you to our Individual Policy partners, EHealth and BuyerZone)
(Selecting this answer will redirect you to our Individual Policy partner)
2
or more - Please indicate the exact number:
(Answer with numbers only, --
e.g., 4, not four.)
Please note: The number you enter should reflect
only eligible employees and should not include any spouses or dependents.
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| 2) |
Do you currently offer group health insurance coverage? [required] |
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No
Yes -
Please provide the health plan & expiration date:
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| 3) |
If you do currently offer a group health plan to your employees, what
types of coverage are available?
(please check all that apply) |
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None
currently
HMO
PPO
POS
(Point of Service)
Self-insured
Other
or not sure
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| 4) |
What types of health insurance plans are you currently considering? [required]
(please check all that apply) |
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Not
sure - please help me to determine the best plan for our needs
HMO
- managed care system with fairly strict in-network regulations
PPO
- more flexible system; permits out-of-network visits with higher co-pay or deductible
POS
- most flexible managed care system; open access to providers with plan covering
a lower percentage of costs from out-of-network providers
Self-insured
- employees deposit premiums into company health insurance fund
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| 5) |
What types of coverage would you like in addition to primary medical? [required]
(please check all that apply) |
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Dental
insurance
Wellness
programs - discounts to fitness clubs, massage therapy, etc.
Prescription
drug plan - comes standard with most plans
Vision/eyewear
plan - comes standard with most plans
Not
sure
None
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| 6) |
In which state(s) do you have employees residing? [required]
(please list all states - ex. MA, MI, IL) |
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| 7) |
How many years has your company been in business? [required] |
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| 8) |
How many eligible employees do you have within each of the following groups? [required] |
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Single employee(s) |
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Married/legally cohabitating - employee plus spouse, no children* |
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Single employee(s) with one or more children - employee plus dependents; no spouse |
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Employee(s) with families - spouse and one or more children* |
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*Please note: States have varying definitions
of what constitutes an "employee and spouse" relationship; please refer any questions
regarding domestic partner eligibility to the suppliers that respond to your request. |
| 9) |
What is the five digit ZIP code for your office location? [required] |
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Zip lookup for major cities
- Albuquerque, NM - Zip: 87199
- Arlington, TX - Zip: 76001 - 76019
- Atlanta, GA - Zip: 30301 - 31199
- Austin, TX - Zip: 73301 - 78799
- Baltimore, MD - Zip: 21075 - 21298
- Boston, MA - Zip: 02101 - 02297
- Charlotte, NC - Zip: 28201 - 28299
- Chicago, IL - Zip: 60601 - 60827
- Cleveland, OH - Zip: 44101 - 44199
- Colorado Springs, CO - Zip: 80901 - 80997
- Columbus, OH - Zip: 43085 - 43299
- Dallas, TX - Zip: 75201 - 75398
- Denver, CO - Zip: 80002 - 80299
- Detroit, MI - Zip: 48201 - 48288
- El Paso, TX - Zip: 79901 - 88595
- Fort Worth, TX - Zip: 76101 - 76199
- Fresno, CA - Zip: 93650 - 93888
- Honolulu, HI - Zip: 96801 - 96850
- Houston, TX - Zip: 77001 - 77299
- Indianapolis, IN - Zip: 46201 - 46298
- Jacksonville, FL - Zip: 32099 - 32290
- Kansas City, MO - Zip: 64101 - 64999
- Las Vegas, NV - Zip: 89044 - 89199
- Long Beach, CA - Zip: 90745 - 90899
- Los Angeles, CA - Zip: 90001 - 91335
- Louisville, KY - Zip: 40201 - 40299
- Memphis, TN - Zip: 37501 - 38197
- Mesa, AZ - Zip: 85201 - 85277
- Miami, FL - Zip: 33010 - 33299
- Milwaukee, WI - Zip: 53201 - 53295
- Minneapolis, MN - Zip: 55199 - 55488
- Nashville, TN - Zip: 37201 - 37250
- New Orleans, LA - Zip: 70112 - 70195
- New York, NY - Zip: 10001 - 10292
- Oakland, CA - Zip: 94601 - 94666
- Oklahoma City, OK - Zip: 73101 - 73199
- Omaha, NE - Zip: 68046 - 68198
- Philadelphia, PA - Zip: 19019 - 19255
- Phoenix, AZ - Zip: 85001 - 85099
- Portland, OR - Zip: 97200 - 97299
- Sacramento, CA - Zip: 94203 - 95899
- San Antonio, TX - Zip: 78201 - 78299
- San Diego, CA - Zip: 92101 - 92199
- San Francisco, CA - Zip: 94101 - 94199
- San Jose, CA - Zip: 95101 - 95196
- Seattle, WA - Zip: 98101 - 98199
- Tucson, AZ - Zip: 85701 - 85777
- Tulsa, OK - Zip: 74101 - 74194
- Virginia Beach, VA - Zip: 23450 - 23479
- Washington, DC - Zip: 20001 - 56920
NOTE: We only serve U.S. businesses at this time. |
| 10) |
What is your e-mail address? [required] |
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Why
we need your email address
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| 11) |
Health plans with higher up-front, employee-paid, deductibles may also
include lower premiums and greater flexibility. Do you have a preference
for this type of plan? |
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Not
sure - please help me select the plan that best meets my needs
Yes
- we would prefer a plan with higher deductibles
No
- we would like to offer a plan with lower deductibles
(may result in higher premiums or co-insurance cost for employees)
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| 12) |
Census: If 10 or fewer employees
will be enrolled in the small business health insurance plan, please complete
the following census for each employee, indicating sex, age, type of coverage
needed and the employee's home zip code.
Please note: If
you have greater than 10 employees, the vendor will be contacting you for
the census information.
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| 13) |
Please note any other considerations you would like suppliers to be aware
of relating to your group health insurance inquiry: |
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Note: There is a 1,000 character limit for this answer. |
