| Short Term Disability
Does your company offer or provide short term disability coverage for your employees? [ ] Yes [ ] No What length of service is required before employees are eligible for short term disability? [ ] 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?____% What percentage of the income does the employee receive? _______% What is the elimination period before disability is paid? [ ] None [ ] 5-7 days [ ] 2 weeks [ ] 30 days [ ] Other_________________ What is the maximum number of weeks the employee is covered for? _____________ |
| Long Term Disability
Does your company offer or provide long term disability coverage for your employees? [ ] Yes [ ] No What length of service is required before employees are eligible for long term disability? [ ] 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?____% What percentage of the income does the employee receive? _______% What is the elimination period before disability is paid? [ ] None [ ] 5-7 days [ ] 2 weeks [ ] 30 days [ ] Other_________________ What is the maximum length of benefit? _____________ |