Sample Employee Benefits Survey Template

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SAMPLE Employee Benefits Survey
ABC Company strives to provide valuable, comprehensive and affordable benefit programs
for our employees. Each year, we review our current programs — particularly our health and
dental plans — to ensure they live up to these goals and are meeting our employees’ needs.
Please take a few moments to complete this survey and help us with our annual benefits
review process. Your input is important to us regardless of whether or not you currently
participate in any of the programs.
Please return the completed survey to Jane Jones at ABC Company
Thank you.
1. Are you currently enrolled in the employee health care plan?
Yes
No
2. If you answered no to question 1, are you:
Covered under spouse’s plan?
Covered under another plan?
Uninsured?
3. If you do not have health insurance, are you uninsured because of:
Cost
Other
- please explain: ________________________________
4. Are you currently enrolled in the employee dental care plan?
Yes
No
5. If you answered no to question 4, are you:
Covered under spouse’s plan?
Covered under another plan?
Uninsured?
6. If you do not have dental insurance, are you uninsured because of:
Cost
Other
- please explain: ________________________________
7. How would you rate the information you receive about your benefit plans?
Excellent
Above average
Average
Below average
Poor
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Parent category: Life
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