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 ___________________________________________