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Employer Group Health Insurance Profile
*
Indicates required field
Company Name
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Industry
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Years in Business
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Primary Contact
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First
Last
Title
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Business Address
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Line 1
Line 2
City
State
Zip Code
Country
SIC Code
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If not known, provide description of your industry
How much of the premium will you contribute towards employee portion?
Select One
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50% (Minimum)
60%
70%
80%
90%
95%
100%
How much premium will you pay towards dependent portion? (can be any amount from 0-100%)
*
When would you like coverage to start?
*
How long after date of hire until employees become eligible for benefits?
Select One
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Date of hire
First of the month following date if hire
First of the month following 30 days after date of hire
First of the month following 60 days after date of hire
Currently offer group medical insurance?
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Yes
No
Current renewal date?
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Name of Current Medical insurer?
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Phone Number
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Fax Number
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Email
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Number of hours employees must work per week to be eligible for benefits?
Select One
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17.5 (Minimum for insurers)
20
25
30 (Minimum to avoid ACA penalty)
35
37.5
40 (Maximum)
Total number of Owners and Employees on payroll?
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Average number of employees working at least 17.5 hours per week over the last 12 months?
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Number of employees currently eligible for benefits? (Based on those working at least 17.5 hours per week)
*
Currently offer group dental insurance?
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Yes
No
Current renewal date?
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Name of current dental insurer?
*
Comments
*
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