Survey Questions Insurance Continued
Optical Insurance
Does your company offer or provide optical insurance coverage for your employees?
[ ] Yes [ ] No
What length of service is required before employees are eligible for optical insurance?
[ ] Hire Date [ ] End Probation
[ ] One Month [ ] Six months
[ ] Other___________________________
Are all employees eligible for coverage?
[ ] Yes [ ] No
If no, which employees are not eligible? [ ] Part Time
[ ] Other Please explain _____________________________
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? $ _______
Is there a deductible? [ ] Yes [ ] No
If yes, what is the annual deductible? $_______
Please check all components covered under your plan? [ ] Annual Eye Exam
[ ] Prescription Glasses
[ ] Prescription sun glasses [ ] Prescription Safety Glasses
[ ] Contacts [ ] Other___________________________
Is there a maximum benefit level?
[ ] Yes [ ] No
How many employees are currently insured on your plan? 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 If yes, please explain
___________________________________________
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