JRB Insurance LLC - Group Benefits Inquiry

Your company & who to talk to

So James knows who he's working with and where the group is located — rates and carrier availability both vary by address.

Company name

Industry or type of business

Your first name

Your last name

Your title / role

Email

Phone

Business street address

City

State

ZIP code

County

Any additional locations or employees working in other states? (optional)

Best way to reach you (select all that apply)

Phone call Text Email No preference

Please select at least one contact method.

Your current plan

The single most useful thing you can do is attach or email your renewal letter. These questions cover the rest.

Current medical carrier

Plan name or type

Renewal date

How long with this carrier? (optional)

How is the plan funded?

Fully insured Level funded Self funded Not sure

Please select one option.

How many medical plan options do employees choose from?

One Two Three or more

Please select one option.

What increase were you quoted at renewal? (percent or dollar amount, if you know it)

Who's on the plan

Counts only here — no names needed. If James quotes anything, he'll send a separate census spreadsheet for the detail.

Total employees

Eligible for coverage

Actually enrolled

Waiving coverage

Dependents enrolled (approx.)

Employees age 65+

Employees age 60–64

Part-time employees

What's the waiting period for a new hire?

Please select one option.

Cost & what the company pays

Approximate is fine. This is what determines whether a change actually saves the company money or just moves it around.

Current total monthly premium (company + employee)

Target monthly budget, if you have one (optional)

How much does the company pay toward the employee's own premium?

Please select one option.

How much does the company pay toward dependent premiums?

100% Partial Nothing Not sure

Please select one option.

Are employee premiums payroll deducted pre-tax through a Section 125 / POP plan?

Yes No Not sure

Please select one option.

Other benefits already in place

Often there's more room to improve here than on the medical plan, and it can usually be done without touching your renewal.

Which of these does the company currently offer? (check all that apply)

Which would you like looked at? (check all that apply — no obligation)

Employees approaching or past 65

For companies under 20 employees, Medicare interacts with a group plan differently than most people expect. These answers tell James whether that's worth a conversation here.

To be clear about how this works: whether to enroll in Medicare is entirely each employee's own decision, made with their own advisor. An employer can't require it, steer it, or offer any incentive tied to it. Nothing in this section is a recommendation to anyone — it just tells James whether your employees would benefit from having someone available to answer their Medicare questions individually and confidentially.

Are any employees or their spouses currently enrolled in Medicare?

Yes No Not sure

Please select one option.

Have employees asked you questions about Medicare that you weren't sure how to answer?

Yes, more than once Once or twice No

Please select one option.

Would it help to have someone available to your employees for individual Medicare questions, at no cost to the company?

Yes Maybe, tell me more No

Please select one option.

What's driving this

What made you start looking? (check all that apply)

Please select at least one.

If you could only fix one thing, which would it be?

Lower cost to the company Lower cost to employees Better benefits, same money Better network access Less admin work

Please select one option.

Any specific doctors, hospitals, or prescriptions that have to stay covered? (optional)

Timing & decisions

Who decides on benefits?

I do I recommend, owner decides A group decides

Please select one option.

Where do things stand with your current broker?

Happy, want a second opinion Open to changing Looking to replace No broker currently

Please select one option.

How soon would you like to talk?

This week Next two weeks Within a month Planning for next year

Please select one option.

Two documents make all the difference: your renewal letter with the new rates, and a completed census. Please email them to james@jrbinsurance.com after you submit this form — and if you don't have a census template, just say so below and one will be sent to you.

Do you need a census template?

Yes, please send one No, already have it

Please select one option.

Anything else

Anything else that would help? (optional)

Separately, I'd also like information about: (optional — for you personally, not the company)

Medicare Individual / family health (ACA) Annuities / retirement income Life insurance Long-term care Social Security analysis Nothing else right now

Tell us about your group

Your company & who to talk to

Your current plan

Who's on the plan

Cost & what the company pays

Other benefits already in place

Employees approaching or past 65

What's driving this

Timing & decisions

Anything else

Your summary