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First Name
Last Name
Business Name
Organization Type
Do you have any Benefits Plan currently?
Do you have any Retirement Plan currently?
Approximate Number of Employees on Benefits

Current Coverage Include (Select Yes to All that Apply)

Life Insurance
Prescription Drugs
Dependent Life (Spouse / Child)
Paramedical Practitioners (Physio, Massage, etc.)
Accidental Death & Dismemberment (AD&D)
Vision Coverage (Glasses / Contacts)
Short Term Disability
Basic Dental (Cleaning, Periodontic, Endodontic)
Long Term Disability
Major Dental (Crowns, Bridge etc.)
Critical Illness
Employee Assistance Program (EAP/EFAP)
Health Spending Account (Non-Taxable)
Diagnostic And Second Medical Opinion Services
Wellness Spending Account (Taxable)

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