Wufoo

National Congregational Health Insurance Survey

Please submit this form no later than, November 7, 2012.

In order to develop a proposal to present to congregations, insurance brokers require specific information regarding your current participating employees. Complete one form for each eligible employee.

You need not complete the whole survey at once. Once you have submitted employee information to the survey you can go back and continue to add your participating employees until the survey is completed for each person you employ.

Would you be interested in joining a national consolidated medical plan, if pricing and plan were attractive? *
Yes No
How many people do you employ? *
How many part time employees do you have? *
How many employees are currently participating for your medical plan? *
Do you offer health care to your part time employees? *
Yes No
What is the total annual health care insurance cost for your Synagogue? * $ Dollars . Cents
Synagogue Name *
Street Address
City *
State *
Zip Code
Synagogue Phone Number * ### - ### - ####
First name of person completing this form *
Last name of person completing this form *
Email of person completing this form? *
If possible, Attach a File: Copy of Recent Invoice (Must Show Monthly Rate)
If possible, Attach a File: Copy of Plan Summary (info about Deductible, CoPay, etc.)
Do Not Fill This Out