Dodd & Associates - Benefits Department
Client Census - Confidential
Client Name: Date: Contact:
Current Effective
Street Address: Phone: Cell: Fax:
Date:
Requested
City/State/Zip Email Address:
Effective Date:
BELOW ARE EXAMPLES CLASSES OF EMPLOYEES THAT WILL BE CUSTOMIZED TO FIT YOUR COMPANY
Class 1: Employer 100% for
Owner 20/hr Probationary Period: 1st of mo. Contribution:
100 % EE
Depend
Current Insurance Broker:
Employer 0% for
Class 2: Managers 32/hr Probationary Period: 30 days Contribution:
100% EE
Depend
Industry: Yrs in bus:
Class 3: Employer 0% for
Full Time 32/hr Probationary Period: 90 days Contribution:
75% EE
Depend
Fed ID # SIC Code:
Disability Class Date Date Date Date Date
Quote and of of of of of
Eligible Employees Employee Only Date Smoking Date Birth Birth Birth Birth Birth EE
ID Monthly of Y = yes of Insured Insured Insured Insured Insured Zip
Last Name First Job Title Number Salary Hire N = no Birth Age Gender Spouse Child Child Child Child Code
1
2
3
4
5
6
7
8
9
#
Not Eligible due to probationary period
1
2
Not eligible due to hours worked
1
2
Waived - on another creditable medical plan
1
2
Employees on COBRA
1
2
$ -
Dodd & Associates
425-513-8463 direct
425-920-8227 fax HEALTH RISK QUESTIONNAIRE - To the best of your knowledge... Do not inquire of employees
Benefits@DA-Connections.com RFP Due Date: Have you ever been covered by WAHIT? No
Do you have a drug screening
program?
No
Do you offer a smoke-free
Client Name: Will this group be submitting an individual health questionnaire? No workplace? Yes
Has this group ever had the quoted rates or new group rates increased Any EE or dependents
Address: due to IHU by an HMO, HSC or insurance co.? No pregnant? No
Do you offer injury prevention
City / State / Zip: Have you ever had rate increases due to individual health underwriting? No classes? No
Industry Years in Business: In the past or next 12 months, any health claim to exceed $5000? No
Has anyone covered under this plan been treated for a serious illness or
SIC Code: Owners Covered (L&I): injury? No
Are any participants absent from work now, near future; at home,
Locations other than WA: hospital, nursing home, hospice care, etc., or phsically or mentally No
incapacited?
CURRENT PLAN - No current group plan, individual plans only
Medical Dental Vision Other
Current Renewal Current Renewal Current Renewal Current Renewal
Employee
Spouse
Child
Family
Current Carrier
# EE on Cobra
Plan design
Deductible / Copay
Stop Loss
Options Ortho TMJ
Benefit Maximum
Other
NOTES: