HCA Service Automation

1. Name of school district

2. Name of person submitting report

3. Email address of person submitting report

4. Phone number of person submitting report

5. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

6. Carrier/insurer/vendor

7. Contract period beginning month

8. Premium payment method (If "Other", please describe)

	Additional Information

9. Number of employees enrolled (or best estimate)

Range: 1 - 5000

10. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

11. Additional information about this benefit option you’d like HCA to know

12. Do you have another optional benefit to report?

13. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

14. Carrier/insurer/vendor

15. Contract period beginning month

16. Premium payment method (If "Other", please describe)

	Additional Information

17. Number of employees enrolled (or best estimate)

Range: 1 - 5000

18. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

19. Additional information about this benefit option you’d like HCA to know

20. Do you have another optional benefit to report?

21. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

22. Carrier/insurer/vendor

23. Contract period beginning month

24. Premium payment method (If "Other", please describe)

	Additional Information

25. Number of employees enrolled (or best estimate)

Range: 1 - 5000

26. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

27. Additional information about this benefit option you’d like HCA to know

28. Do you have another optional benefit to report?

29. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

30. Carrier/insurer/vendor

31. Contract period beginning month

32. Premium payment method (If "Other", please describe)

	Additional Information

33. Number of employees enrolled (or best estimate)

Range: 1 - 5000

34. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

35. Additional information about this benefit option you’d like HCA to know

36. Do you have another optional benefit to report?

37 Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

38. Carrier/insurer/vendor

39. Contract period beginning month

40. Premium payment method (If "Other", please describe)

	Additional Information

41. Number of employees enrolled (or best estimate)

Range: 1 - 5000

42. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

43. Additional information about this benefit option you’d like HCA to know

44. Do you have another optional benefit to report?

45. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

46. Carrier/insurer/vendor

47. Contract period beginning month

48. Premium payment method (If "Other", please describe)

	Additional Information

49. Number of employees enrolled (or best estimate)

Range: 1 - 5000

50. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

51. Additional information about this benefit option you’d like HCA to know

52. Do you have another optional benefit to report?

53. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

54. Carrier/insurer/vendor

55. Contract period beginning month

56. Premium payment method (If "Other", please describe)

	Additional Information

57. Number of employees enrolled (or best estimate)

Range: 1 - 5000

58. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

59. Additional information about this benefit option you’d like HCA to know

60. Do you have another optional benefit to report?

61. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

62. Carrier/insurer/vendor

63. Contract period beginning month

64. Premium payment method (If "Other", please describe)

	Additional Information

65. Number of employees enrolled (or best estimate)

Range: 1 - 5000

66. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

67. Additional information about this benefit option you’d like HCA to know

68. Do you have another optional benefit to report?

69. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

70. Carrier/insurer/vendor

71. Contract period beginning month

72. Premium payment method (If "Other", please describe)

	Additional Information

73. Number of employees enrolled (or best estimate)

Range: 1 - 5000

74. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

75. Additional information about this benefit option you’d like HCA to know

76. Do you have another optional benefit to report?

77. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

78. Carrier/insurer/vendor

79. Contract period beginning month

80. Premium payment method (If "Other", please describe)

	Additional Information

81. Number of employees enrolled (or best estimate)

Range: 1 - 5000

82. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

83. Additional information about this benefit option you’d like HCA to know

84. Do you have another optional benefit to report?

85. Type of benefit (If "Other", please describe) (Options listed are not meant to imply that districts have the authority to offer them)

	Additional Information

86. Carrier/insurer/vendor

87. Contract period beginning month

88. Premium payment method (If "Other", please describe)

	Additional Information

89. Number of employees enrolled (or best estimate)

Range: 1 - 5000

90. Is this optional benefit available to all bargaining units? (If "No", please indicate which bargaining unit is eligible for this optional benefit)

	Additional Information

91. Additional information about this benefit option you’d like HCA to know