Compnay result

Does your Company provide medical benefits in addition to the medical benefits provided the social security system?

Yes

No

Are all employees equally eligible for all benefits?

Yes

No

How is the plan funded?

Employer Funded

Employee Funded

Shared Funding: Are the contributions a fixed amount or a percentage of salary?

Employee Portion ----------%

Employer Portion ----------%

Define the salary used to compute the premium payment.

Gross

Basic

Do you self-insure or do you have Medical Insurance Plan Provider?

Medical Plan

Self

Which insurance company do you use?

________________________________________________

Eligibility for the Active Medical Plan.

Spouse (# of spouses) -----------------

Children Age -----------------

Children Age If full time Student -----------------

Age Limit In case of Handicapped -----------------

Step Children Yes No

Parents Yes No

How is the cost of dependent coverage paid?

Employer funded

Employee funded

Shared funding: Are the contributions a fixed amount of a percentage of salary?

Employee portion: -----------% or Fixed Amount: ------------------------

Employer portion:-----------% or Fixed Amount: ------------------------

Is there an age limit for coverage?

Yes

No