Washington State SHRM Employee Benefits Survey Questions

Please Note: This document is for informational purposes only. It is intended to help

you gather the information you need to complete the online survey. Every survey

question is included in this document; however, when completing the online survey, you

will only view the questions applicable to you.

0 First of month following 30 days of employment

O First of month following 60 days of employment

0 90th day of employment

0 Other

Which of the following healthcare plans does your organization offer?

Select all that apply.

0PPO

0HMO

0HDHP

D Other

Healthcare Premiums

What are the total monthly premiums and percent of premiums paid for your

healthcare plan?

Enter the total monthly premium paid by both employer and employee and the percent of premium paid by your organization

for the following group(s).

If the employee pays 100% of premium and your organization makes no contribution, enter "0" for "% Paid by Employer".

Include medical costs only; do not include vision or dental costs.

Do not include $ or % symbols.

» Employee only

» Employee + Spouse

» Employee + Registered DomesticPartner

» Employee + Child(ren)

» Employee+ Family

$ Total Monthly Premium % Paid by Employer

What are the deductibles and out-of-pocket maximums for your healthcare plan?

In-Network Out-of-Network

$ Deductible $ Out-of-Pocket Max $ Deductible $ Out-of-Pocket Max

Individual

What are the deductibles and out-of-pocket maximums for your healthcare plan?

» Employee Only

» Employee + Spouse

» Employee +Registered DomesticPartner

» Employee +Child(ren)

» Employee + Family

Medical Flexible Spending

Account (FSA)

Dental & Vision Benefits

Health Savings Account (HSA)

Does your organization offer vision or dental coverage?

Yes; bundled in

Health Reimbursement

Arrangement (HRA)

[ l

healthcare coverage Yes; offered separately

Vision coverage

Dental coverage

0

0

0

0

Which of the following groups are offered vision coverage?

Select all that apply.

D Employee only

D Employee + Spouse

0 Employee + Registered Domestic Partner

D Employee+ Child(ren)

D Employee + Family

Defined Contribution Health Plan

No; not offered

0

0

What are the total monthly premiums and percent of premiums paid for your vision

plan?

Enter the total monthly premium paid by both employer and employee and the percent of premium paid by your organization

for the following group(s).

If the employee pays 100% of premium and your organization makes no contribution, enter "0" for "% Paid by Employer". Do

not include $ or % symbols.

0 Traditional defined benefit pension plan (frozen to current employees/not open to new hires)

D Supplemental executive retirement plan (SERP)

0 Profit-sharing plan

D No retirement benefits offered

Retirement Benefit Funding

How is your organization's retirement plan funded?

0 Employee contribution only

0 Company contribution only

0 Company contributes only if employee contributes

0 Company contributes and employee may contribute

0 Other

What type of contribution does your organization make to this plan?

0 Discretionary

0 Safe harbor contribution

0 Formula match

For discretionary contributions to this plan: What percentage of each employee's pay does

your organization contribute?

0 1.0-1.9%

0 2.0-2.9%

0 3.0-3.9%

0 4.0-4.9%

0 5.0-5.9%

0 6.0-6.9%

0 7.0-7.9%

0 8.0-8.9%

0 9.0-9.9%

0 10.0% or more