CONFIDENTIAL Information for Health Plan Analysis Please complete the questions below so that we can get started preparing your cost-savings analysis. Question Title * 1. Company Information Company Name Street Address City, State, Zip Question Title * 2. Your Information Your Name Phone Email Question Title * 3. Health Plan Information (Provide approximate information) Number of Employees Enrolled in Health Plan Amount or Percentage of Premium Paid By Employer Total Monthly Health Insurance Premium Plan renewal date Expected renewal change (if known) Question Title * 4. How is Your Health Plan Funded? Fully Insured Self-Insured Minimum Premium Other/Unsure Fully Insured Self-Insured Minimum Premium Other/Unsure Question Title * 5. The following statement best describes our employees' opinions about our health plan(s): Our employees are very satisfied with our plans. We hear very few negative comments. We hear some negative comments, especially regarding the payroll deduction costs and out-of-pocket costs due to high deductibles. We hear quite a few complaints about costs, access to care, and other issues. Our employees are very dissatisfied with our health plan. Question Title * 6. The following statement most closely describes my level of urgency in reducing health plan costs: I’d like to learn more about this new approach. Saving money is not especially urgent. I’m concerned about cost increases and would like to save money, but I don’t want my company or our employees to face a lot of changes. I’ve had it with the relentless cost increases and, if this new approach makes sense and doesn’t cause too much disruption, I will seriously consider it. My back is against the wall. I need to lower my health insurance costs now. Question Title * 7. Prefer to speak to me personally? Call me directly at 1-800-346-4015 or enter your phone number here for me to call you Submit