HEALTH:
Do you currently have Health Insurance?: Yes No

If Yes, What Carrier? Yes No

If No, would you be interested in a quote?: Yes No

Do you cover employees?: Yes No

Do you have an: HMO POS PPO Don’t Know

What are you Rates?: Single Husband/Wife Employee & Child(ren) Family

What are your Co-Pays?: Primary Specialist Hospital Prescription

DENTAL:
Do you currently have Dental Insurance?: Yes No

Do you cover employees?: Yes No

If you don’t currently have Dental, would you be interested in a Quote?: Yes No

NY STATE DISABILITY:
Would you be interested in a decreasing your cost?: Yes No

WORKERS’ COMPENSATION:
Who is your current carrier?:

Would you be interested in a quote?: Yes No

PROPERTY & CASUALTY(Liability/Fleet/Property):

Would you be interested in a quote?: Yes No

RETIREMENT PLANNING:
Do you have a Retirement Plan in place?: Yes No

Is it a 401K plan?: Yes No

If No, would you be interested in a quote Yes No

COLLEGE SAVINGS PLAN:
Do you have a Retirement Plan in place?: Yes No

Is it a 401K plan?: Yes No

LIFE INSURANCE:
Do you have a Retirement Plan in place?: Yes No

Is it a 401K plan?: Yes No

LONG TERM CARE COVERAGE:
Do you have a Retirement Plan in place?: Yes No

Is it a 401K plan?: Yes No

VOLUNTARY BENEFITS:
Would you be interested in the following coverage(s) for your employees that they fully pay for (not you) & it’s portable: Cancer Care:Yes No

Short-Term Disability: Yes No

Accident: Yes No

Critical Illness: Yes No

Vision: Yes No

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