Medical Insurance Survey

Dear Associates,

As we continue to grow, we are working on offerings for employees – please answer the below questions, as this will help us all. Your responses have no impact on the great job you perform within the company. If you have any questions, please reach out to me, but in all seriousness this questionnaire should take no more than 2 minutes to complete.

Thank you,

Mike

Name*

First Name Last Name

Date of Birth*

MM slash DD slash YYYY

Zip Code*

ZIP Code

Do you have medical insurance?*

Yes

No

What is the name of your medical insurance carrier?

Do you receive ConnectorCare Plans (subsidized public health insurance)?

Yes

No

Who is the Primary insured?

What is the Plan Type?

Do you have a dental plan?*

Yes

No

What is the name of your dental insurance carrier?

Who is the Primary insured?

What is the Plan Type?

Are you enrolled in Medicare?*

Yes

No

Do you have Part A?

Yes

No

Do you have Part AB?

Yes

No

Do you have Supplemental Insurance?

Yes

No

Who is your supplemental insurance with?

If you want a copy of this questionnaire sent to you – please enter email address.

(this is totally optional)

Comments

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