CHC GROUP CENSUS | CHC Agents

CHC CENSUS
Please put "N/A in box if not applicable

Agent Name

Phone Number

Client Informatin

Address

City

State

Zip Code

Type Of Business

# Of Employees

ATNE

# Of Locations

Client's Budget

Plan Design

Have they had insurance previosly

Type

With Who

Have they ever worked with a broker

Are they currently working with a broker? Who?

Do they currently have insurance? If Yes See Below

Why are they looking for coverage

Current Carrier

HSA Y/N

HRA Y/N

Number of plans offered

Current rates and renewel rate

Copays

OPP

Deductible

Community or age brand premium

% paid by employee and % paid by employer

# Of Employees Enrolled

Why are they looking for health insurance now for their group

Perferred Copays

Perferred OPP

Perferred Deductible

Have they considered a monthly budget for their premiums

Do they offer life or disability

Would they like to present voluntary employee paid dental, vision, or other to offset out of pocket costs? (Y/N - Which?)

Would they like quotes

Preferred Carriers to quote

Carriers to avoid

Thanks for submitting!