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Health Insurance Survey

We are currently reviewing health insurance renewal options with our insurance provider as well
as bids from other insurance carriers to offer the best and most cost-effective insurance
coverage to our employees. Your feedback is important in this process. Please take a few
minutes to complete this survey and return it to Human Resources by [date].

1. Type of health coverage elected: (Circle one)

Limited Family
Full Family (Employee,
(Employee + Spouse
None Single Spouse
or Employee
+ Children)
+ Children)

If “None” was circled, please complete this section:

_______ I have coverage elsewhere

_______ I cannot afford coverage at this time

_______ Coverage is affordable but not elected

2. I am happy with our current network of doctors/hospitals through the current provider:
(Circle one)

Somewhat
Strongly Agree Somewhat Agree Neutral Strongly Disagree
Disagree

3. Approximate amount you have paid out of pocket this calendar year for health claims
(office visit co-pays, deductibles, co-insurance and prescription costs): (Circle one)

$0 - $500 $501 - $1,000 $1,001 - $1,500 $1,501 - $2,000 $2,001 or more

4. Rank in order of importance to you regarding your health insurance:


(Rank 1 through 5, 1 being the most important to you, 5 being the least)

_______ Cost of health insurance premiums per paycheck

_______ Out-of-pocket costs (deductible, office co-pays, co-insurance, prescription co-pays)


_______ Network of doctors/hospitals

_______ Customer service support on claims questions

_______ Timeliness of claims processing

5. Rate your overall level of satisfaction with the current health insurance carrier: (Circle
one)

Very Somewhat Somewhat Very


Neutral
Satisfied Satisfied Dissatisfied Dissatisfied

6. I would be interested in electing supplemental benefits such as:

________ Additional life insurance for family members and myself

________ Additional long-term disability coverage

________ Long-term care for dependents or myself

________ Additional short-term disability coverage

________ Cancer insurance, accident policy, hospital indemnity plan

________ Pet insurance

7. Type of dental coverage elected: (Circle one)

Limited Family
Full Family (Employee,
(Employee + Spouse
None Single Spouse
or Employee
+ Children)
+ Children)

If “None” was circled, please complete this section:

_______ I have coverage elsewhere

_______ I cannot afford coverage at this time

_______ Coverage is affordable but not elected

8. Rate your level of satisfaction with your current dental coverage: (Circle one)
Very Somewhat Somewhat Very
Neutral
Satisfied Satisfied Dissatisfied Dissatisfied

9. Rank in order of importance to you regarding your dental insurance:


(Rank 1 through 5, 1 being the most important to you, 5 being the least)

_______ Cost of dental insurance premiums per paycheck

_______ Out-of-pocket costs (deductible, co-pays, co-insurance)

_______ Network of dentists

_______ Customer service support on claims questions

_______ Timeliness of claims processing

10. Child orthodontics is an important coverage option on the dental plan: (Circle one)

Somewhat
Strongly Agree Somewhat Agree Neutral Strongly Disagree
Disagree

Additional comments:

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