Employer Qualifying Questionnaire

WellthCare Qualifying Questions

Two short steps. Then Sample Agent schedules your compliance Zoom consultation and walks you through your preliminary savings estimate.

If you have multiple companies to qualify, please input and qualify each company separately.

1Qualify

2Company & Payroll

3Consultation

Tell us about you

Your details and a quick estimate of the positive financial impact for your company.

A Your details

Company Name *

Title *

First Name *

Last Name *

E-mail *

Phone *

I agree to allow WellthCare to contact me at the number and email provided on matters related to my application using automated technology, including calls, texts, and pre-recorded messages. You may opt-out at any time by replying 'STOP'. *

B Estimate the Positive Financial Impact with the WellthCare Health Management Plan

This is for estimate purposes only. The actual number will be based off of documents submitted. Potential impact is based on the employee count and average salary.

Number of full-time employees *

Health Insurance Provider (if applicable)

What was the average salary paid to your employees? *

Representative Number (for internal use)

Step 1 of 3

Company & Payroll Information

Please complete the questions below and click continue.

A Company Information

Company Name *

Payroll Contact *

Contact

E-mail *

Phone *

B Payroll System

What Payroll System do you use? *

Payroll Representative Name

Phone

Payroll Census Reporting Example

Eligibility Information

Last Name
DOB
SSN
Email
Phone Number
Full Address

Payroll and W4 Information

Current Payroll Gross Pay
Pay Cycle/Schedule
Federal and State Marital Status
Federal and State Exemptions
Dependent Tax Credit - 2020 Tax Law Change
Pre and Post-Tax Deductions (If Applicable)
Employee ID or Payroll ID

Thank you for completing the first step!

Based on your answers, we will generate a preliminary savings estimate for your company. Your estimated savings and program eligibility will be reviewed with you during your Zoom compliance consultation.

Employee census (optional, but speeds things up)

To finalize your qualification and savings analysis, we will also need an employee census. Please use the payroll example provided in the previous step as a guide when preparing the census.

You may provide your employee census in advance or at the time of your consultation. If providing it in advance, email it directly to Sample Agent at sample.agent@example.com.

Once received, we can finalize your company's qualification and projected savings and have it ready for review at your compliance consultation.

✓ Next Step: Compliance Zoom Consultation

Availability. Please list three (3) days and times. We will do our best to schedule within your availability.

Day *

Time *

Date *

Day *

Time *

Date *

Day *

Time *

Date *

REMINDER: Please download or print a copy of this form for your records before submitting.