Online Client Questionnaire

Client Questionnaire

Company Name *

Locational Address *

Postal Address *

Tel No. *

Total No. Of Offices & Locations *

Total Number of Employees *

Male *

Female *

Age Range *

Average Age *

Cover For Dependents *

Yes

Total No. Of Dep. To Be Covered If Yes *

Spouses *

Children *

Age Limit For Children *

Type Of Health Plan Sought *

TPA

Insurance

Briefly Describe The Nature Of Your Work *

Have You Ever Purchased Health Insurance For Your Employees? *

Yes

If Yes, Please Indicate Premium Paid

Text

If No, What Healthcare System Did You Have In Place?

If No, What Healthcare System Did You Have In Place? *

How Much Do You Spend Per Employee On Healthcare Under This System?

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