Cafeteria Plan
Which of the following insurance premiums are eligible to be deducted as pretax dollars under a section 125 cafeteria plan?
[ ] Medical Plan [ ] Dental Plan [ ] Optical Plan [ ] None [ ] Other 
Medical Insurance
Does your company offer or provide medical insurance coverage for your employees? [  ]  Yes [  ]  No
What length of service is required before employees are eligible for medical insurance?
[ ] Hire Date [ ] End Probation [ ] One Month [ ] Two Months [ ] Three Months [ ] Other 
Are all employees eligible for coverage? [  ]  Yes [  ]  No
If no, which employees are not eligible? [ ] Part Time [ ] Other Please explain below

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Is coverage paid for by the Company? [   ]  Yes [   ]  No If yes, what percentage is company paid?__________ %
Is dependent coverage paid for by the Company? [   ]  Yes [   ]  No If yes, what percentage is company paid?__________ %
What is the monthly cost to the employee for: Employee coverage? $_________    Dependent coverage? $________
What type of insurance do you offer? [ ] Major Medical [ ] PPO [ ] HMO

[ ] Other________

What is the annual deductible?    $__________ What is the employee's maximum out-of-pocket expense?    $_________
Which of the following cost containment features does your plan utilize?
[ ] Second Opinion [ ] Pre-Certification [ ] Utilization Review [ ] None

[ ] Other______

How many employees are currently insured on your plan?

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Is your company self-insured?

[  ]  Yes   [  ]  No

Are employees responsible to pay the company portion of the premium during leaves or other extended absences?
[  ]  Yes [  ]  No

SOURCE: hrVillage.com
Human Resources

Human Resources

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