Employee Benefits Survey Questionnaire

							DATE: TO: FROM: RE: EMPLOYEE BENEFITS SURVEY ALL ___________________________ EMPLOYEES

The overall objective of our employee benefit program is to provide peace of mind for you and your family members from financial hardship in the event of an accident or sickness, disability, retirement or death. Additionally, we strive for programs that are user friendly, promote healthy lifestyles, fit employee needs, offer high value and can be judged superior to industry averages. In light of these objectives, we are continually faced with financial pressure to manage cost and obtain the best value for the money spent on our benefit program. With this in mind, we are asking you to complete the attached survey to help us understand your individual and family needs. Your response may be anonymous and all responses will be kept confidential. We have engaged the services of Clark Benefits, an employee benefits consultant, to conduct this survey and make recommendations for plans that meet our needs. From the data collected, we will analyze the following: 1) 2) 3) 4) Your satisfaction with our current benefits; The type of benefits which are offering the best value to you and your family; Your understanding of the benefit options; What benefits you would like to see added or changed.

We appreciate your quick response to the survey and request you return the completed questionnaire to your supervisor by 00/00/00. We will provide you with a summary of the results, which highlight the impact to you. Thank you again for your cooperation.

EMPLOYEE BENEFITS SURVEY

(1)

Your age:

Under 30 30 to 39 40 to 49 50 to 54 55 to 59 60 to 64 65 or Older

_____ _____ _____ _____ _____ _____ _____

(2) (3) (4) (5)

Your gender: Do you smoke: Is it fair to give an incentive to employees who are non-smokers and generate lower claims than smokers? Length of service with our company:

Male _____ Female _____ Yes _____ No _____ Yes _____ No _____ Less than 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years 10+ Years _____ _____ _____ _____ _____

(6) (7)

Do you believe the benefit program should provide additional benefits for longer term employees? Your marital status:

Yes _____ No _____ Single _____ Married - Single Income _____ Married - Dual Income _____ Single w/child(ren) Single w/o child(ren) Married w/child(ren) Married w/o child(ren) $20,001 - $40,000 $40,001 - $60,000 $60,001 - $80,000 $80,000 - $125,000 $125,001 or more _____ _____ _____ _____ _____ _____ _____ _____ _____

(8)

Dependent status:

(9)

Your annual salary:

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PARTICIPATION
(1) Medical: (a) Are you eligible for medical insurance through any other source (i.e. spouse) (b) (c) (d) (2) If yes, are you covered under that plan? Are your dependents eligible for medical insurance through any other source? Are your dependents covered under that plan?

Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____

Dental: (a) Are you eligible for dental insurance through any other source (i.e. spouse) (b) (c) (d) Are you covered under that plan? Are your dependents eligible for dental coverage through any other source? Are your dependents covered under that plan?

Please indicate the degree of importance or value you attach to each of the following benefits:

Very Important 1 2 a) b) c) d) e) f) g) h) i) j) k) Medical Insurance Dental Insurance Life Insurance Vision Care Long Term Disability 401(k) Plan Flexible Benefits (Pre-tax) EAP Vacation Holidays Sick Days ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

3 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Least Important 4 5 ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

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HEALTH COVERAGE
HMO Plan: Complete this section if you are enrolled in an HMO (1) (2) The HMO plan that you are enrolled in? When was the last time you or a family member used the HMO plan: __________________________ Never Used 1 - 3 Months Ago 4 - 6 Months Ago 7 - 12 Months Ago 13+ Months Ago _____ _____ _____ _____ _____

(3) (4)

If you have called for an urgent visit, were you scheduled for an appointment that day: If you have called for a regular appointment, how long do you usually wait for an appointment: If you needed to be referred to a specialist, how long did the referral process take:

Yes _____ No _____ 1 - 2 Weeks _____ 3 - 4 Weeks _____ 5+ Weeks _____ 1 - 2 Weeks _____ 3 - 4 Weeks _____ 5+ Weeks _____

(5)

(6)

If you have used your HMO doctor, how would you rate the following: Excellent 1 2 Good 3 Poor 4 5

a) b) c) d) e) f) (7)

Convenience of office location: Hours when office visits can be scheduled: Thoroughness of exams and accuracy of diagnosis: Ability to diagnose problem quickly: Quality of doctors and hospitals in network: Size of provider network: Would you prefer the option to see a doctor outside the HMO Network for office visits? If yes, what additional amount per month would you be willing to pay for this option: Yes _____ No _____ $5 - $15 $16 - $25 $26 - $50 $51 or More _____ _____ _____ _____

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PPO/POS Plan: Complete this section if you are enrolled in a PPO/POS Plan (1) When was the last time you or a family member used the Group medical PPO plan: Never Used 1 - 3 Months Ago 4 - 6 Months Ago 7 - 12 Months Ago 13 + Months Ago _____ _____ _____ _____ _____

(2)

If you have used the PPO/POS, how would you rate the following: Excellent Good 1 2 3 Poor 4 5

a) b) c) d) e) (3)

Convenience of office location for provider in network: Hours when office visits can be scheduled: Ability to diagnose problem quickly: Quality of doctors and hospitals in network: Size of provider network: Did your doctor require payment up-front or did they bill our insurance company: Payment Up-Front ____ Billed Insurance Company ____

TO BE COMPLETED BY ALL EMPLOYEES

(1)

How do you rate the importance of your current physician relationship:

Very Important _____ Somewhat Important _____ Not Important _____

(2)

If you were given the choice between maintaining your current doctor relationship and paying an additional fee or change to a different list of providers and not pay more, which would you choose? Maintain Current (add’l fee) _____ Change (no increase) _____

(3)

Would you be willing to pay to participate in the following programs:

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a) b) c) d) e) (4)

Dental Insurance Short Term Disability Long Term Disability Vision Care Supplemental Life Insurance

Yes Yes Yes Yes Yes

_____ _____ _____ _____ _____

No No No No No

_____ _____ _____ _____ _____

If yes, what is the maximum contribution you would be willing to pay for coverage on a monthly basis: ($5-$10) ___ ($5-$10) ___ ($5-$10) ___ ($5-$10) ___ ($5-$10) ___ ($11-$20)___ ($11-$20)___ ($11-$20)___ ($11-$20)___ ($11-$20)___ ($21-$30)___ ($21-$30)___ ($21-$30)___ ($21-$30)___ ($21-$30)___ ($31 +)____ ($31 +)____ ($31 +)____ ($31 +)____ ($31 +)____

Dental STD LTD Vision Life

PRE-TAX REIMBURSEMENT ACCOUNTS

(1)

SECTION 125 (MEDICAL PREMIUM ACCOUNT) (Allows you to save approximately 25% by paying your health plan contributions on a pre-tax basis.) (a) Do you understand the tax advantages of the Medical Premium Account (pay for benefits with pre-tax dollars): Yes _____ No _____

(2)

SECTION 105 (HEALTH CARE REIMBURSEMENT ACCOUNT) (Allows you to save approximately 25% by paying for health care expenses on a pretax basis.) (a) (b) Do you understand the tax advantages of the Section 105: How much money per year would you estimate you and your family currently spend for health services that are not paid by insurance (i.e. deductible, coinsurance)? Yes _____ No _____ $500 or less _____ $501 - $1000 _____ $1000 or More _____

(3)

SECTION 129 (DEPENDENT REIMBURSEMENT ACCOUNT) (Allows you to save approximately 25% by paying adult and child care expenses not covered by insurance on a pre-tax basis.)

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(a)

Do you understand the tax advantages of the Section 129: How much money per year would you estimate you and your family spend for adult or child care?

Yes _____ No _____ $500 or less _____ $501 - $1000 _____ $1000 or More _____

(b)

TO BE COMPLETED BY ALL EMPLOYEES
(3) How do you perceive: a) Communication of our benefits program: Excellent Above Average Average Below Average Poor Excellent Above Average Average Below Average Poor Less than $1,000/yr $1,001 - $2,000 $2,001 - $3,000 $3,001 - $5,000 $5,001 - $8,000 $8,000 or More Excellent Above Average Average Below Average Poor _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

b)

Your understanding of benefits offered to you:

(4)

In your opinion, what is the total cost paid by our company for your benefits, including paid time off:

(5)

Please tell us how you feel our benefits program, in total, measures up to what other similar situated companies offer:

(6)

If you have other comments or opinions concerning our current benefits program, or benefits that you would like to see offered, please share them with us here: (please be as specific as possible) -6-

__________________________________________________________________ _ __________________________________________________________________ _ __________________________________________________________________ _ __________________________________________________________________ _ This information will be analyzed and used to design your benefits! Thank you for your input.

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