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Employee Benefits Interest Form

Company Name

*

Contact Person

Full Name:

*

Title/Role:

*

Email

*

Phone Number

*

Business location (Zipcode & State)

Zip Code

*

How many employees do you currently have?

*

How many employees do you currently have?

1–10

11–25

26–50

51–100

100+

How many office locations or branches does your company have

*

How many office locations or branches does your company have

1

2–3

4–5

6–10

11+

What employee benefits do you currently offer (if any)?

*

What employee benefits do you currently offer (if any)?

What are your top priorities for offering or improving benefits?

*

What are your top priorities for offering or improving benefits?

Do you have a current broker or benefits provider?

*

Do you have a current broker or benefits provider?

Yes

No

When would you like to implement or update benefits?

*

When would you like to implement or update benefits?

ASAP

Within 1–3 months

Within 6 months

D) Just exploring for now

How would you prefer to receive information?

*

How would you prefer to receive information?

Email

Phone call

Schedule a Zoom meeting

In-person visit (if applicable)