EMPLOYEE BENEFITS FORM

EMPLOYEE BENEFITS FORM

Please complete the form below to let us know what benefits you might be interested in. We will respond promptly with suggestions for improving the cost effectiveness of your present benefits coverage.

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Company Information Our services are currently available for employers in AR, AL, LA, MS, TN

Company Name:		Phone:
Address:		Fax:
City, State, Zip:		Contact Name:
Email Address:

A. Health Insurance

Current Health Insurance Company Name:
	Fully insured		HMO (health maint. organization)
	Self-funded		PPO (preferred provider org)
	Self-funded with stop loss		POS (point of service)
	Indemnity plan		Physician co-pay
	More than one level of coverage offered		Prescription drug plan (separate)

B. Dental and/or Vision Insurance

Dental Insurance: Vision Insurance:
E. Additional benefits you might want to offer to your employees on a voluntary basis

	Short Term Disability		Legal services plan
	UL and/or Term life insurance		Educational assistance
	Cancer expense Insurance		Long Term Disability
	Long Term Care Insurance		Critical Illness Insurance
	Additional employee and/or dependent term life insurance		Cafeteria Plan (IRC Section 125)

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