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Health & Wellness Plan
Client Questionnaire
Company Information
Business Name (Legal Entity Name)
Business Street Address
Business City
Business State
Business Zip Code
Phone
Email
How Many Full Time W2 Employees?
How Many Part Time W2 Employees?
Does this group have a major medical health plan?
*
Yes
No
Who is your Major Medical Provider?
Payroll Provider
Please Select
If "Other"
Average Employee Salary
Pay Cycle?
Please Select
Submit
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