Care for Good Interest Form - Delaware Alliance for Nonprofit Advancement (DANA)

Care for Good Interest Form

Thank you for your interest in DANA’s Health Insurance Solutions. By completing this brief interest form, you will enable our broker partner, Weiner Benefits Group, to develop a Care for Good proposal and estimated rates tailored to the plans your organization is interested in pursuing.

Fields marked with an * are required.

Please verify that you have checked the “I'm not a robot” checkbox.

Organization Name *

Organization Mailing Address *

Name of Primary Contact Person *

Phone number for Primary Contact *

Please use the format (xxx)xxx-xxxx

Email Address for Primary Contact *

Is your organization a current DANA Member? *

Yes

How many full-time employees do you employ? *

Do you currently offer a group health insurance benefit? *

Yes

If yes, who is your current health insurance carrier?

For example: Highmark, Aetna, United Health, Cigna, Other

If yes, how many employees are enrolled in your current health insurance group plan?

What is your organization’s group health insurance plan renewal month?

Do you currently work with a broker for your health insurance?

Yes

If yes, who is your broker?

Are you interested in receiving information on any other type of employee benefit insurance?

If so, please check the types of insurance you are interested in:

Dental

Vision

Short-term Disability

Long-term Disability

Parental Leave Insurance

Identity Theft Insurance

Retirement Planning

Please indicate any additional employee benefits or insurance offerings not listed above.

Please describe additional benefits in the space below.