Kentucky Non Profit Network Employee Benefits Program Question Title * 1. What is your organization's name? Question Title * 2. What is your organization's physical address (if different from mailing address)? Please include City, State & Zip Code. Question Title * 3. What is your organization's mailing address? Please include City, State & Zip Code. Question Title * 4. What county are you located in ? These counties are not eligible for the health plan (Bullitt, Hardin, Jefferson, Oldham, Shelby, Spencer & Trimble). However, all counties are eligible for the dental and supplemental benefits. Question Title * 5. What is your full name? Question Title * 6. What is your title? Question Title * 7. What is your e-mail address? Question Title * 8. What is your organization's phone number? Question Title * 9. What is your organization's FAX number? Question Title * 10. Are you currently a KNN member? Yes No Question Title * 11. How many full-time eligible employees (working 30 or more hours/week) work for your organization? NOTE: at least two eligible employees are required to enroll for there to be a group plan. Question Title * 12. How many part-time employees (work less than 30 hours per week) work for your organization? Question Title * 13. Are you interested in a group health plan? Yes No Question Title * 14. Who is your current health insurance carrier? Question Title * 15. What is your current health insurance plan renewal date? Please enter a date... Date Question Title * 16. Are you interested in a group dental plan? Yes No Question Title * 17. How many employees are currently enrolled in your health insurance plan? Question Title * 18. Are you interested in supplemental benefits? Yes No Question Title * 19. If interested in supplemental benefits, which benefits? ALL Life Short-Term Disability Accident Hospitalization Critical Care Cancer Question Title * 20. How soon are you interested in learning more about the KNN benefits? Right away, we need to make a change as soon as possible Within the next 3-6 months This would be a future consideration for us in the next 12 months or more Question Title * 21. Do you have any other comments, questions, or concerns? Done