Paul Davis, Insurance and Financial Services, Home On The Web

We are performing an evaluation of our employee benefits. We need your help. Please complete the following and return as soon as possible.
FAX
(818) 993 1497

NOTE: We are not planning any radical changes. But we will use your input to help decide any changes, additions, or deletions in coverage.

NAME:_____________________ Date of Birth: ___/___/___ Married? YES__ NO__

Number of dependents ____ What city do you live in? ______________ Zip Code ______

If married, does your spouse have health insurance through their employer? YES__ NO ___

If yes:

Are you covered under your spouses’ plan? YES___ NO___

What is your monthly cost for coverage under that plan? (estimate) $_____

What type of health insurance would you prefer?

HMO____ PPO____ Choose your own doctor ____

POS (Combines HMO and PPO)____ Depends on cost ____

How would you rate our current benefits?

Excellent Good Fair Poor Not Used Didn’t Know We Have

HEALTH _____ _____ _____ _____ ______ ______

DENTAL _____ _____ _____ _____ ______ ______

VISION _____ _____ _____ _____ ______ ______

DISABILITY _____ _____ _____ _____ ______ ______

PENSION _____ _____ _____ _____ ______ ______

COMMENTS:___________________________________________________________

_______________________________________________________________________

Are you pleased with the providers available on our current Health Plan? YES ___ NO___

COMMENTS:_______________________________________________________________

List any companies you WOULD like to use: _____________________________________

__________________________________________________________________________

List any companies you WOULD NOT like to use: _________________________________

__________________________________________________________________________

Are you able to pay a portion of the cost? YES ___ NO ___ DEPENDS ___

Which benefits are you most interested in (Rank 1-6 :

Health Insurance ___ Dental Insurance ___ Life Insurance ___ Vision Care ___ Pension Plans ___ Other ________________

Comments, questions, or suggestions: _____________________________________________

___________________________________________________________________________

Please list the Physicians and Hospitals you must have access to on any health plan:

Doctors’ Name Specialty City

_______________________________________________________________________

Would you like anyone to contact you regarding any supplemental individual plans? YES__ NO ___

THANKS!!!

Telephone
(818) 888-0880 (800) 487-0880
FAX
(818) 993 1497
Postal address
P.O. Box 7265 Van Nuys CA 91409-7265