Employer Survey

Thank you for taking the time to fill out this brief enrollment survey. It will help us start the process to determine if your business is eligible for the SharedCare Plan. We will review the information provided and contact you shortly.

If you have any questions, or if you would like to talk to someone in person, please contact our Enrollment office by contacting 541-647-1765 ext 303.

Company Name:

Address:

City:

State:

Zip:

Business Phone Number:

Email:

Contact/Owner/Manager:

Do you have W2 employees?

YesNo

Do you currently offer traditional health insurance to any employees?

YesNo

If yes, with who?

Do you have uninsured employees? (No coverage through spouse, OHP, etc.)

YesNo

Do they work at least 15.4 hours?

YesNo

Have they been on the payroll a minimum of 8 weeks?

YesNo

How did you hear about us?