Group Health Questionnaire

Business Name*:

Mailing Address:

Street Address:

Contact Person*:

Phone*:

Email*:

Fax:

Business Type: Select Business Type Corporation Sole Proprietor Partnership LLC

Tax ID Number:

How long has business been established in California?    years / months

Are all of your employees located in California
(51% must be in CA)?

 Yes No

Requested Effective Date:

Select the effective date 1st of the next month 15th of the next month

How many employees do you have?

Eligible Employees

Quantity

Owners

Full time employees (30 hours or more per week)

Part time employees (less than 30 hours per week)

W-2 only, No 1099s, Leased or Commissioned 

Ineligible Employees

New hires (still in probationary period)

Medi-Cal or Medicare eligible (over age 65)

Military coverage

Other group coverage
(i.e., spouse’s group plan, eligible dependent on parent’s group plan, or other employment)

Must enroll 75% of eligible employees to qualify for group plan

What portion of the employee premium do you plan to pay?
 *Must be either:  at least 50% of employee monthly premium,at least $100 per employee per month or a percentage of a specific plan’s premium.

%  or $

What portion of the dependent premium do you plan to pay?
*not required, no minimum required.

%  or $

Will you offer benefits to part time employees
(less than 30 hours per week)? *Not required to offer

 Yes No

Probationary period/waiting period for new employees:
(90 days, 6 mos, etc.)

Do you currently carry group insurance?

 Yes No

If yes, list carrier name

Do you carry Workers Compensation Insurance?

 Yes No   
Renewal Date?                 

List employees below:

Name of Employee (Last name, First name, M.I.) Date of Birth Home ZIP Code Spouse? Y or N No. of Children 1  Yes  No 2  Yes  No 3  Yes  No 4  Yes  No 5  Yes  No 6  Yes  No 7  Yes  No 8  Yes  No 9  Yes  No 10  Yes  No

* Indicates required field