2019 TPMA BENEFITS SURVEY
Progress: 
 
Note:  If more than one health plan is offered, complete chart for each plan.
 
1.
Please enter the information indicated below about the person filling out the survey.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com

2.
What is the number of enrolled employees?
 

50 characters left.
3.
Please list monthly employee contributions for each category below (ONLY include payroll deductions): 
         Single:
         Employee/Spouse:
         Employee/Child:
         Employee +1:
         Family:
 

350 characters left.
4.
Please list total monthly premiums for each category below (Includes employee and employer amounts.  For self funded plans, use COBRA rates.)
         Single Rate and #Enrolled
         Employee/Spouse Rate and #Enrolled
         Employee/Child Rate and #Enrolled
         Employee + 1 Rate and #Enrolled
         Family Rate and #Enrolled

 

350 characters left.
5.

Fully Insured or Self Funded?

Fully Insured
Self Funded
  • Comment:

  • 500 characters left.
6.
Name of Carrier or TPA
 

50 characters left.
7.
Do you have both In & Out of Network benefits?
Yes
No
8.
Health Plan Renewal Month
 

50 characters left.
9.
Single/Family Deductible
 

50 characters left.
10.
Single/Family Maximum Out of Pocket (includes deductible)
 

50 characters left.