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Bene-Care Benefits Audit

Contact Information
Name:*
Company:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:*
Preferred method of communication:
Information for Audit
County for Headquarters:
Number of employees (total):
Number of employees eligible for benefits:
Number of participants:
Employer Contribution
Current Carriers:
Current Premiums:
Do you offer pre-tax options? (Section 125/105)
Do you offer any of the following:
Not Offered Shared Employer Paid Employee Paid
Dental
Life
STD
LTD
LTC
Additional Comments/Questions:

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