Employee Questionnaire

Please fill out the following form to help determine which coverage policy or policies would best suit your specific needs.

All information listed will be kept 100% confidential.

First & Last Name

Desired Start Date:

Zip Code

Date of Birth

Are you looking for Dental/Vision coverage as well?

Yes, Both

Yes, Dental

Yes, Vision

Neither

Are you (and/or your spouse/dependent(s) [If any] nursing any health conditions, or taking any daily prescriptions

Yes

If you answered yes to this question, please elaborate which conditions/medications apply, and to which candidate(s). If you answered no, state "None"

If any, please list genders/dates of birth of all others needing coverage, and/or any additional information that may be potentially useful in determining which policy will best suit your specific needs:

Email Address

Phone Number

Please expect an initial call/text/email from myself or a direct colleague of mine.

This information will never be shared anywhere else.

Company Name

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Your employer and I thank you for your prompt response & submission!