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Group Health Employee Benefits Survey


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
Required
Do you have any active employee's age 65 or older?
Optional
How many full-time employees do you have working 25 hours or more a week?
Optional
How many part-time, temporary or seasonal employees do you have?
Optional
Do you currently have a flex plan in place?
Optional
Are you familiar with the State and/or Federal employment laws regarding continuation of coverage for terminated employees (Cobra)?
Optional
Are you familiar with the new Health Care Reform Regulations?
Optional
Are you familiar with the rules regarding adding or removing members from your health plan?
Optional
Have you reviewed your group life, group dental, disability or long-term care coverage recently?
Optional
Have you considered voluntary benefits such as those offered by AFLAC?
Optional
Are you interested in having your policy paid through your payroll service?
Optional
Comments:
Optional
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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