Please enter the following information to receive a Benefit Credits Proposal designed for a specific employer.

IMPORTANT NOTE: If you’re the employer, please tell us specifically how you learned about Benefit Credits. Thank you!

Benefit Credits form to Compare to Current Benefit Program
* Required
How did you learn about Benefit Credits? *
This is the association's name, your broker's name, on your own, etc.
Your answer
Employer Name *
Your answer
Employer Location (U.S. State) *
If multiple States, please separate with commas.
Your answer
Contact Email *
This is where the proposal will be sent.
Your answer
Contact Phone Number *
So we can contact you. We may have questions or need clarification on your answers.
Your answer
Current Health Consultants Name
Your answer
Total Monthly Health Insurance Premium for the Group *
(Not the cost per individual)
Your answer
What Percentage do you pay towards Health Insurance? *
Choose
0%
20%
30%
40%
50%
75%
80%
90%
100%
Recently, what percentage Health Insurance increase have you had? *
This is to adjust for medical inflation. Typically it is 7% to 15% per year.
Choose
5%
7%
10%
15%
20%
25%
30%
35%
40%
50%
Monthly Dental Insurance Premium
Your answer
What Percentage do you pay towards Dental Insurance?
Choose
0%
20%
30%
40%
50%
75%
80%
90%
100%
Monthly Life Insurance Premium
Your answer
What Percentage do you pay towards Life Insurance?
Choose
0%
20%
30%
40%
50%
75%
80%
90%
100%
Monthly Other Employee Benefits Premium
Other benefits could include gym memberships, or other supplemental insurance products.
Your answer
What Percentage do you pay towards Other Employee Benefits?
Choose
0%
20%
30%
40%
50%
75%
80%
90%
100%
Total Number of Employees in your company *
FT, PT and Employees who have other coverage as well
Your answer
How many Employees use the Health Insurance Benefit. *
This should not be a percent.
Your answer
What Percentage of Employees Earn Below $35,000 Per Year? *
Guestimate...
Choose
0%
20%
30%
40%
50%
75%
80%
90%
100%
Submit
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