| Employer: |
|
|
Employee Benefit
Planning Survey |
|
Premium Only 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 |
| 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: |
|
