1.Your name

2.Your role

Broker

Employer

3.Employer Legal Name

4.Employer FEIN

-Enter nine numerical digits. Include leading zeros.

5.Which Memorial Hermann program are you reporting about?

-Employers who offered both programs (at different times), must complete this survey twice, separately about each.

Hybrid

Fully Insured

6.Total premium paid by the employer

-The total of the overall premium total funded by employer contributions during the entire reference year for the program being reported. This is NOT a percentage. It is total dollar amount for the entire period.

7.Total premium paid by members

-The total of the overall premium funded by participants. Includes payroll deductions and COBRA and/or state continuation payments made by terminated employees. This is NOT a percentage. It is total dollar amount for the entire period.

8.Overall total premium paid

-This is the overall total paid to Memorial Hermann. If this figure does not equal the sum of the employer and member contributions reported above, this survey will be discarded.