Employer Interest Survey

Employer Interest Form
Company Name: (*)
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Address:
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City:
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State:
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Zipcode:
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Contact Name:
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Phone
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Email Address:
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Do you have W-2 employees?
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Do you offer traditional insurance to any employees?
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Do you have any uninsured employees?
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Do you have uninsured employees that work at least 15 1/2 hrs per week?
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Do you have uninsured workers that have been on payroll at least 13 weeks?
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How did you hear about us?
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Please type in the letters that are displayed Please type in the letters that are displayedClick here if you can't read the letters
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