Census Form for Group Health Quote

To receive a customized EMPLOYEE BENEFITS analysis for your Organization, we need the following information. The below form must be complete to provide you with accurate quotes, if employee data is in an electronic format; you may upload it along with the required fields on this form. There is a place to select the file you want to upload at the bottom of this page. Please put N/A in any field that does not apply and is required.

A representative will contact you to ask any additional questions or clarify any information you have provided. You may attach a file at the bottom of this form with more information on your existing carriers, plan coverage designs and recent invoice/premium rates for your current coverage (if available). This will allow us to search for similar plans (co-pays, deductibles, coverage, etc.). When current invoices are provided we can give you a complete analysis of proposed plans including monthly/annual cost savings vs. just providing proposed rates. You can e-mail this information to us as well at benefits@charterbenefits.com.

All fields marked with a * are required:

EMPLOYER INFORMATION:

Organization Name:* Also Known As:

Address:*    City:*     State:* Zip Code:*

Decision Maker Name:* Organization Phone:*    Ext.

Contact Name:*    Contact Title:*    Contact Email:*

Contact Phone Number:*    Alternative Phone Number:    Fax Number:*

How many Full Time (Eligible) Employees:*    How many Employees expected to enroll in medical plan:*    # of Part Timers: *

Employer Pays* % OR $ of employee cost.   Employer Pays % OR $ of dependant cost.

Do you offer a Section 125 (Cafeteria Plan)* YES NO This allows your employees to pay their share of insurance premiums on a pre-tax basis, allowing your employees to stretch their income. A 125 Plan can also reduce the employer taxes.

Tell us what your goals are for your employee benefit package:*

You may attach a file here with more information on your existing carriers, plan coverage designs and recent invoice/premium rates for your current coverage. If you have more than 50 full time employees please attach a spreadsheet with the above information on your employees here.

Continue to the Employee Information Page.

EMPLOYER INFORMATION:
Organization Name:* Also Known As:
Address:* City:* State:* Zip Code:*
Decision Maker Name:* Organization Phone:* Ext.
Contact Name:* Contact Title:* Contact Email:*
Contact Phone Number:* Alternative Phone Number: Fax Number:*
How many Full Time (Eligible) Employees:* How many Employees expected to enroll in medical plan:* # of Part Timers: *
Employer Pays* % OR $ of employee cost. Employer Pays % OR $ of dependant cost.
Do you offer a Section 125 (Cafeteria Plan)* YES NO This allows your employees to pay their share of insurance premiums on a pre-tax basis, allowing your employees to stretch their income. A 125 Plan can also reduce the employer taxes.
Tell us what your goals are for your employee benefit package:*
You may attach a file here with more information on your existing carriers, plan coverage designs and recent invoice/premium rates for your current coverage. If you have more than 50 full time employees please attach a spreadsheet with the above information on your employees here.