| Employer: |
|
|
Employee Benefit
Planning Survey |
|
Full Plan |
| Name: |
|
| Address: |
|
| City: |
|
State: |
|
Zip |
|
| Social Security # |
|
| Sex: |
Male
Female |
| Date of Birth: |
|
Date of
Hire: |
|
| Tax Status: |
Married
Single
Head of Household |
Number of
Dependents: |
|
| Gross Pay: |
$ |
# of Pay
periods |
|
|
I. Employee Payroll Deduction
Items |
| Group Medical Insurance |
$ |
per pay
period |
| Group Disability
Insurance |
$ |
per pay
period |
| Group Dental Insurance |
$ |
per pay
period |
| Group Accident Insurance |
$ |
per pay
period |
| Group Cancer Insurance |
$ |
per pay
period |
| Group Term Life
Insurance |
$ |
per pay
period |
| Total Expenses Sect. I |
$ |
per pay period |
|
II. Unreimbursed Medical
Expenses |
| Deductibles |
$ |
per year |
| Co-Insurance |
$ |
per year |
| Physicals |
$ |
per year |
| Prescription Drugs |
$ |
per year |
| Other |
$ |
per year |
Total Expenses
Sect. II |
$ |
per year |
|
III. Unreimbursed Dental
Expenses |
| Check-ups & Cleanings |
$ |
per year |
| Orthodontics |
$ |
per year |
| Treatments |
$ |
per year |
Total Expenses
Sect. III |
$ |
per year |
|
IV. Unreimbursed Vision &
Hearing Expense |
| Exams |
$ |
per year |
| Contacts |
$ |
per year |
| Glasses |
$ |
per year |
| Hearing Aids |
$ |
per year |
Total Expenses
Sect. IV |
$ |
per year |
|
V. Dependent & Child Care
Expenses |
| Child Care Expenses |
$ |
per year |
| Nursing Home Expenses |
$ |
per year |
| Private Nursing Expenses |
$ |
per year |
Total Expenses
Sect. V |
$ |
per year |
| I understand
that this is a survey only and does not obligate me in any way. I
authorize my Employer to release any information from my payroll record that
is necessary to complete this survey. |
| Employee Signature: |
|
| Date: |
|
