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Please complete this form to help us prepare a Benefit/Cost Analysis on our Professional Employer Organization Services
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Company          Email
Contact Name   Title  
Address             City   
State                 Zip    
Phone               Fax   

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Type of Business
SIC Code
Description of Business and Products

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COMPANY INFORMATION

Total Number of Employees
 Full Time
 Part Time
Monthly Payroll

Unemployment Rate % (UC-27 Form)

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EMPLOYEE BENEFIT INFORMATION

Current Carrier
Description of Coverage
For multiple Selections hold the CTRL key down while clicking

Total number of employees enrolled in your company's health plan

No. of Employees with coverage for

Full Family Employee/Spouse
Employee/Child Employee Only

Please list your employer/employee contribution to your health plan
(Example: employer pays 60%, employee pays 40% = 60/40)

Coverage

Full Family Employee/Spouse
Employee/Child Employee Only

Please list your current health plan monthly premium for the following coverage:

Coverage

Full Family Employee/Spouse
Employee/Child Employee Only
Does your company offer a dental plan to your employeers?      Yes  No
(if yes please give the breakdown of employees who elect this coverage)

Coverage

Full Family Employee/Spouse
Employee/Child Employee Only

(if yes what are your monthly dental premiums for the following coverage)

Coverage

Full Family Employee/Spouse
Employee/Child Employee Only

Please list your employer/employee contribution to your dental plan
(Example: employer pays 60%, employee pays 40% = 60/40)

Coverage

Full Family Employee/Spouse
Employee/Child Employee Only

Does Your Company Offer the Following

Pre-Tax Section 125 Yes No

Pension Plan Yes No

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HUMAN RESOURCE   INFORMATION

Does your company offer a Safety Program? Yes No
Do you have a Substance Abuse Policy? Yes No
Do you have an Employee Problem Solving Policy? Yes No
Does your company use a Payroll Service? Yes No
Does your company have a Human Resource Manager? Yes No
Do you run a pre-employment and/or random MVR on Drivers? Yes No

 



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