Custom Data Form by qqs20207

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									     Data Request Form
     Thank you for initiating a custom cost analysis with Emeriti. When you have completed the form, please email it to swajda@emeritihealth.org.


I.   Contact Information                                                                       II. Employee Census Data
                                                                                                                                                                     Employee Count
                                                                                                                                           Active                              Retired
                                                                                                                                                                Pre-Medicare           Medicare Eligible
                                                                                                                                          Benefit                       Spouse/                  Spouse/
       Date:                                                                                          Age Demographics:                   Eligible          Retirees   Partner 1     Retirees    Partner 1
                                                                                                       21-24
       Institution Name:                                                                               25-29
       Address:                                                                                        30-34
                                                                                                       35-39
                                                                                                       40-44
                                                                                                       45-49
       Contact Name:                                                                                   50-54
       Telephone:                                                                                      55-59
       Email                                                                                           60-64
                                                                                                       65-69
                                                                                                       70-74
                                                                                                       75-79
                                     `                                                                 80-84
                                                                                                       85-89
                                                                                                       90-94
                                                                                                       95-100
                                                                                                         Total                                    -                 -                 -        -       -
Notes:
  1 If spouse/partner is benefit eligible please provide as much data as possible.


IMPORTANT INFORMATION: Illustrations created by requested data are not intended to provide a definitive representation of your organization’s particular situation. They have been generated
by inputting certain economic, financial and demographic assumptions into a modeling tool. You are responsible for determining whether the assumptions used and outputs generated
accurately reflect your organization’s unique circumstances.
                                                                                                                                                                                                          -
                                                                                                                                                                                                          Yes
     Data Request Form
     Thank you for initiating a custom cost analysis with Emeriti. When you have completed the form, please email it to swajda@emeritihealth.org.


III. Salary Information                                                                                IV. Retiree Benefits Data
                                                                                                                                                                                                              Pre-65         Post 65
     Average Salary                                                                                         Do you have employer sponsored group medical plan for retirees?                                      -              -
      Entry Level Assistant Professor                                                  $                     If yes, please answer the following questions:

       Full Professor (65 years old)                                                   $                         Average monthly premium for benchmark plan?                                                    $               $
                                                                                                                 What is the EMPLOYER share of total premium:
     Aggregate Payroll                                                                                               Retiree?                                                                                   $               $
      Benefit Eligible Employees                                                       $                             Spouse/Partner?                                                                            $               $
      Benefit Eligible Employees (40 + years old)                                      $                         Who is your benchmark carrier?                                                               Name            Name
                                                                                                                 Is the plan self funded?                                                                        -              -
                                                                                                                 Does premium include administrative costs?                                                      -              -
                                                                                                                 If available please include a copy of the plan SPD.




                                                                                                                                                                                                          -              -
                                                                                                                                                                                                          N/A            N/A
                                                                                                                                                                                                          Yes                       30
                                                                                                                                                                                                          No                        40
                                                                                                                                                                                                                                    50

IMPORTANT INFORMATION: Illustrations created by requested data are not intended to provide a definitive representation of your organization’s particular situation. They have been generated by inputting certain economic, financial
and demographic assumptions into a modeling tool. You are responsible for determining whether the assumptions used and outputs generated accurately reflect your organization’s unique circumstances.
                                                                                                                                                                                                                                     70
                                                                                                                                                                                                                                     80
                                                                                                                                                                                                                                    100

								
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