09 Agency Survey

This is my form. Please fill it out.

Name*

Agency*

Number of Full Time Employees*

Number of Part-Time Employees*

Number of employees eligible for health insurance benefits*

General eligibility for Insurance: full/part time*

New hire waiting period for eligibility.*

What coverage does your agency provide – please check

Employee Only
Employee plus partner
Employe plus family

Premium sharing cost for Employee only*

Premium sharing cost for Employee plus partner*

Premium sharing cost for Employee plus family*

Name of current health insurance provider*

Name of current dental insurance provider*

Name of current vision insurance provider*

What is your current cost of insurance?*

What is your current annual deductibles?*

What is your current co-pays?*

What is your current Rx coverage?*

Do you have a Contingency plan for higher-than-anticipated premium increases?*

What is your employee raise amount for current year?*

Current salary for Executive Director/CEO*

Current Salary for Program Director*

Current Salary for Office Manager*

What is the percentage amount of budget for agency overhead costs?*

Do you have a conflict of interest policy?

yes no