Employee Benefit Solutions

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Name of Company: SIC#:
Address:    
     
City:    
State:    
Zip:    
Contact Person:    
Phone:    
Email:    
Desired Effective Date:    

Employee Name Age Spouse # of Children Job Title Salary/Wage

Please check desired options:

Health Insurance
    Deductible Option:  $250  $750  $1,000  $1,500  $2,000
    Co-Pay Office Visit:  Yes  No Amount: $500 Maternity  Yes  No
    Co-Insurance:  90%  80% Stop Loss:  $5,000 and/or  $10,000
    Preference:  IHC  Blue Cross  United Health  Altius  Starmark  Fortis
    Health Savings Account:  Yes  No

Dental:  Yes  No With Ortho:  Yes  No
Group Life Insurance:  Yes  No
With Accidental Death & Dismemberment  Yes  No
Group Disability: Short Term:  Yes  No Long term:  Yes  No
Retirement Planning:  Yes  No  Owners  Employees  Both