PHI Application – Federal Wellness Program

Preventative Health Initiative Questionnaire

First Name

Last Name

Phone

Company

Job Title

Address

City

State

Postal code

Website

Industry

Business Profile Section

Do you offer Group Health Insurance?

Yes No

Do you have 10 or more W2 Full-Time Employees?

Yes No

Number of total W2 employees?

Number of total Full-Time W2 employees?

Number of total Part-Time W2 employees?

Average Annual Earnings of Full-Time W2 employees?

Average Earnings of Part-Time W2 employees?

Which Payroll Software Do You Use?

Agent Full Name

Agent Email

Client Notes For Consultation