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Employee Benefits Survey Sample


Dear Employee,

We would like to know more about your preferences in order to make better decisions about employee benefit plan(s). Please answer the following questions and give this form to ______________ by_________. Thank you very much for your cooperation.

Name (OPTIONAL) ___________________________


Your Location (PLEASE PROVIDE) ___________________________


1.0 Rank the following in order of your preference for medical plan benefits
(1 = most acceptable; 5 = Least acceptable)

( ) Higher premium payroll deductions
( ) Higher doctor visit co pay
( ) Higher specialist visit co pay
( ) Higher prescription drug co pay
( ) Higher deductible (for hospitalization & other items not covered by co pays)

2.0 Which of the following medical insurance plan types would your prefer?

( ) HMO
( ) PPO
What's the difference between a PPO and an HMO?
There are many differences between them, but the most significant difference is how you access care.

If you're covered by a PPO plan, you have the option of visiting any doctor. However, if you visit a doctor that is a contracted member of the insurance carrier PPO network, you will receive discounted rates on their services, thus minimizing your out of pocket expenses.

In an HMO plan, you need to access non-emergency care through a designated Personal Physician to be covered. You can choose your own Personal Physician or the insurance carrier will assign one to you.

2.1 Which of the following medical plan benefits are important to you? (Check any that apply)

( ) Pre-Paid Legal Plans
( ) Chiropractic coverage
( ) Acupuncture coverage
( ) Personal Life Insurance
( ) Employee Assistance Program
( ) Other ________________




3.0 Controlling medical plan costs involves restricting choices. Which of the following is the most important to you in your medical plan? (Check one)

( ) Widest choice of providers
( ) No referrals needed for specialist visits
( ) Lowest out-of-pocket costs




4.0 Which of the following is more important to you in your dental plan? (Check one)

( ) Widest choice of providers
( ) Lowest out-of-pocket costs



5.0 Which of the following is more important to you in your dental plan? (Check one)

( ) Higher annual maximum benefit level (E.g. $1,000 increased to $1,500+)
( ) Orthodontia benefits for your child(ren)
( ) Orthodontia benefits for adults

6.0 If a Flexible Spending Account (allows you to pay for health and dependent care expenses with pre-tax dollars. Some examples are: deductibles, co pays, coinsurance, acupuncture, chiropractic, lasik eye surgery, orthodontia expenses, Rx, and more) were available, how much do you estimate you would set aside for these items? (Check one)

( ) Under $100 per year
( ) $100-$499 per year
( ) $500-$999 per year
( ) $1,000-$1,499 per year
( ) $1,500 or more per year

7.0 If Voluntary Benefits (at your cost through payroll deductions) were available to you, which types of coverage would interest you? (Check any that apply)

( ) Dental
( ) Vision
( ) Disability
( ) Life insurance for you and your family members (Universal and Whole Life)
( ) Long term care insurance for you and your spouse, parents
( ) Other – please list ________________________________

8.0 Currently you can invest your 401(k) contributions in several mutual funds (including money market, bond, stocks & bonds, growth, research, and global funds). What other funds or types of funds would you like available for your investments?

( ) None, the current choice of funds is sufficient
( ) List type(s) of funds you would like __________________________________________________ _____


9.0 If you are eligible to participate in the 401(k) and do not, please indicate your reason for not participating.

( ) I save money in other investments
( ) I do not currently save for retirement
( ) I do not understand the 401(k) plan
( ) Other __________________________________________________ _____________________________





10.0 If information about your employee benefit plans were available on the Internet, would you be able to access it?

(___) Yes, I have Internet access at home.
(___) No, I do not have access to the Internet.


Let us know any other comments or concerns about your benefits. Thank you very much for your participation.




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