Just take a moment to fill in this form and VEBA will send to you a written assessment of how we can help you enroll your employees
in voluntary benefits with the revolutionary VEBA Model. There is no cost or obligation for the VEBA assessment of your voluntary benefit needs.

Your contact information:
Name:
Address:
Phone:
Fax:
Email:
Company Name:
Company Information
Number of benefit eligible employees:
500 to 1,000 1,001 to 2,000 2,001 to 5,000 5,001 to 10,000
10,001 to 15,000 15,001 to 20,000 20,001 to 30,000 30,001 to 50,000
50,001 to 100,000 100,001 +    

Number of locations:
1 to 5 6 to 20 21 to 50 51 to 100
101 to 200 201 to 500 501 +  

Description of core benefits:
Health Insurance Dental Plan Group Term Life Insurance
Supplemental Term Life Short- Term Disability Long- Term Disability
Long- Term Care Retirement Plan 401-K
Vision Coverage Legal Care Vacation
Stock Purchase Plan Educational Assistance Plan

How are these core benefits currently enrolled?
Face to Face Meetings Group Employee Meetings
In-bound Call Center IVR Internet

Description of current voluntary benefits:
Life Insurance Short- Term Disability Long- Term Care
Vision Care Legal Care  

How are these voluntary benefits currently enrolled?
Face to Face Meetings Group Employee Meetings
In-bound Call Center IVR Internet
Is employee turnover an issue with your company?