Business Survey Consultative Business Survey CONSULTATIVE BUSINESS SURVEY CUSTOMER PROFILE DATE: BUSINESS NAME: BUSINESS TYPE: YEARS IN BUSINESS: ADDRESS: ZIP: MAIN PHONE: FAX: CONTACT NAME: TITLE: DIRECT LINE: EMAIL: 2ND CONTACT: TITLE: DIRECT LINE: EMAIL: PAYROLL/EMPLOYEE INFO EMPLOYEE COUNT: F/T: P/T: 1099s: PAYROLL FREQUENCY: AVERAGE WAGE: AGE RANGE: GENDER MIX? Payroll Setup: IN HOUSE EXTERNAL BENEFITS YES NO BROKER YES NO BROKER NAME: CURRENT BENEFITS OFFERED PLAN EFFECTIVE DATE: MEDICAL NAME: CO-PAY/CO-INSURANCE: DEDUCTIBLE: WAITING PERIOD: DENTAL NAME: VISION NAME: SHORT TERM DISABILITY LONG TERM DISABILITY SECTION 125 PRETAX PLAN LIFE INSURANCE DETAILS: CONTRIBUTIONS PLAN EFFECTIVE MONTH: EMPLOYER %: EMPLOYEE %: DEPENDENTS? YES NO FEEDBACK WHAT IS YOUR BIGGEST CHALLENGE WITH YOUR BENEFITS PROGRAM? WHAT CHANGES OR ADDITIONS WOULD YOU MAKE IF COST DIDN’T MATTER? DO YOU HOLD REGULAR EMPLOYEE MEETINGS? Y N WHEN ARE THEY? Submit Survey
