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________ |
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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______ |
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How many employees are currently insured on your plan? |
________________ |
Is your company self-insured? |
[ ] Yes [ ] No |
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Are employees responsible to pay the company portion of the premium during leaves or other extended absences? | ||||||
[ ] Yes | [ ] No |