Serving Employers and Association Members

Company Name

Address, City, State Zip

Phone Number

Payroll Cycle Payroll CycleWeeklyBi-WeeklySemi-MonthlyMonthly

Decision Maker Name

Decision Maker Phone

Email Address

Do you have a current Health Plan? Do you have a current Health Plan? Yes No

If yes, when is the renewal date?

Do you contribute to the current health plan? Do you contribute to the current health plan? Yes No

If yes, How much ($ or %) do you contribute to the premium each month?