Questionnaire

Preliminary Client Questionnaire
Company Name:*
How did you hear about us?*
Contact Information
Company Contact Name:*
Company Contact Phone:*
Company Contact Email:*
Employees and Classification
Enter the number of W-2s issued to:
Full Time Employees:*
Part Time Employees:*
Other Employees:*
Do you have Temp Staff?*
Do you have Seasonal Staff?*
For the purposes of this questionnaire, seasonal employees are ones that are only employed for a portion of the year; an employee that works all year but has periodic times of increased hours (such as a retail employees during the holiday season) is not considered seasonal.
Do you have Variable-Hour Staff?*
For the purposes of this questionnaire, a variable-hour employee is one who works dramatically different hours from week-to-week, so that the 30 hour/week threshold for full-time employment is not regularly exceeded. Example: a waitress working 15 hours one week and 45 the next is variable-hour; a mechanic working 38 hours one week and 45 the next is not.
Medical Insurance Information
Do you offer medical insurance to your employees?*
General Information:
Describe how employees pay for coverage:*
Explain coverage as if you were telling a new hire about your benefit plan.
Does the company have any other related companies?*
With Common Ownership
Have you had any major changes to your plan in the past 12 months?*
Such as a new or cancelled plan, a new or sold company, dramatic overhaul of benefits offered or cost structure at renewal, etc.
Anything else we should know, or concerns?

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Preliminary Client Questionnaire

Contact Information

Employees and Classification

Medical Insurance Information

General Information:

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