Evaluation Service Request Form Template

Summary

Receive a free evaluation created for the food service industries; leading you to reduced operating costs and strengthened revenue using group buying power.

Why struggle alone, when you can join with the other businesses in your industry, to strengthen your negotiating and buying capability, and improve profitability for everyone?

You will save on energy, labor, food, insurance, consumable supplies, equipment, maintenance labor, employee benefits and more when you negotiate with strength. Sellers, facing your experienced buyer representatives, quickly sharpen their pencil to offer better rates and customer service. Use of social media will increase your customer exposure and increase ticket value for both in-house and take-out sales.

This evaluation form is a start. Once completed it identifies where savings are possible. Then we begin working to get you that savings.

It’s also free. We just ask that you be willing to consider our recommended changes, for the long-term benefit of your business. Now, just complete the brief survey and submit it to get started.

Your Company Name: *

Your Full Name: *

First Name Last Name

Position Title *

Best Number to Reach You *

- Area Code Phone Number

E-mail:

Business Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Identify Your Important Areas of Need *

Energy Reduction (HVAC, Kitchen or Lights) Business Insurance (Workers Comp, Liability, Property or TDI) Personal Insurance (Life, Long-term Care or Disability) Health Insurance (Medical or Dental) Contractor Services (Plumbing, HVAC, Electrical, Pumping, etc.) Supply Vendors (Paper goods, Cleaning materials, etc.) Social Media (Increase Sales, and Improve Customer Experience and Access)

Energy Reduction - select the top areas needing change. These are low cost upgrades to your existing equipment *

Lighting - lower electricity consumption up to 70% Dishwasher - recover and reuse 50% of the heat from drain water Walk-in Coolers & Freezers - lower power by 80% HVAC - reduce the biggest user of electricity

Will you provide a copy of your current Electric/Gas Utility Statement? *

Yes No

Business Insurance - select the top policies needing change *

Workers Compensation - get lower rates Liability and Property (Fire) - better policies at a lower cost Temporary Disability (TDI) - quality local companies are available at low rates Group Life - one policy with minimal coverage for all employees at low cost

Will you provide a copy of your current Business Insurance Policies? *

Yes No Policies are Unavailable

Personal Insurance - select the top policies needing change *

Individual Life - for a few employees Disability - an individual supplement to the medical policy to cover out of pocket medical expenses Long-Term Care - financial security for care due to age or disability

Medical Insurance - select your current carrier(s) needing change *

UHA HMAA Kaiser Permanente HMSA

Please enter the Plan Names(s) or Number, the monthly Single person Premium rate for each Plan AND if prescription drug, vision and dental coverage is included. Example: UHA Plan 600 Single Rate: $300 includes drug, vision and dental *

Getting a rate quotation is easy! Please enter in the box or on a separate list the Name, Gender, Date of Birth and Coverage Level (single, 2-party, family) of each eligible employee and covered dependents. *

Other - please enter your Other Areas of Need: *

We will meet with you to review your request. What is Your First Choice for an appointment?: *

- Month - Day Year

at

: Hour Minutes

What is Your Second Choice for an appointment?: *

- Month - Day Year

at

: Hour Minutes

Please let us know your Comments and Questions that we may address for you:

For the Initial Appointment, we will contact you by phone on either your first or second choice of day and time.

You are welcome to contact Alan Hoki, the Program Administrator, by calling 808-561-0763.

E-mail