Acme Inc.

Health Insurance Evaluation Survey

  1. Instructions

    1. Instructions

  2. Personal Information

    1. *Full Name

    2. *Date of Birth

    3. *Gender

    4. *Marital Status

    5. *Occupation and Employment Status

    6. Annual Income

  3. Insurance Information

    1. *Do you currently have health insurance?

  4. Current Health Insurance Information

    1. *Which provider are you currently insured with?

    2. *How long have you been with your current insurance provider?

    3. What type of plan do you have?

    4. What is your monthly premium?

    5. *Do you feel your current premium is affordable?

    6. *Does your current plan cover your family members?

    7. *Have you experienced any coverage gaps or denied claims in the past year?

    8. Which of the following services are covered under your current plan?

    9. *I have easy access to the information on my plan(s).

    10. *I am satisfied with my current plan.

  5. Financial Considerations

    1. *What is your estimated annual medical expense?

    2. Do you have a Health Savings Account (HSA) or Flexible Spending Account (FSA)?

    3. How important is minimizing out-of-pocket costs for you? (1-5 scale)

    4. Would you be willing to pay a higher premium for more comprehensive coverage?

    5. *How much would you be willing to pay for health insurance monthly?

  6. Health and Wellness

    1. How would you rate your overall health?

    2. Do you have any chronic conditions that require ongoing medical care?

    3. Do you smoke or use tobacco products?

    4. Do you exercise regularly?

    5. How often do you use your current health insurance for medical care?

    6. *How satisfied are you with the process?

    7. Do you anticipate any major medical expenses in the next 12 months (e.g., surgery, childbirth)?

  7. Future Insurance Preferences

    1. Are you considering changing your current health insurance plan?

    2. What are your main reasons for considering a new plan? (Select all that apply)

    3. Are you open to exploring health insurance plans with different providers?

    4. Would you like to receive a customized quote based on your evaluation?

  8. Other Information

    1. Do you have any additional questions or concerns about your health insurance coverage?

    2. Is there anything else you’d like to share about your health or insurance preferences?

Health Insurance Evaluation Survey


Health Insurance Evaluation Survey

Acme Inc.



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    Instructions

    This questionnaire helps us identify areas for improvement and ensure you get the best possible health insurance plan. Please complete this detailed survey to the best of your ability, designed to assess your health insurance needs and satisfaction with current coverage.



    What do you need to know?


    1. Provide all required information here using this form.
    2. Click ✓ Ok to submit and check off each request.
    3. Drafts are saved automatically and your progress restored (so you don't have to complete the checklist in one go


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    Getting started


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    *Response requiredFull Name

    *Response requiredDate of Birth

    *Response requiredGender

    • Male

    • Female

    *Response requiredMarital Status

    • Single

    • Married

    • Divorced

    • Widowed

    *Response requiredOccupation and Employment Status

    • Full-Time

    • Part-Time

    • Self-Employed

    • Unemployed

    • Retired

    • Student

    Annual Income

     Please note that this is in US Dollars.  

    • <$20,000

    • $20-49,999

    • $50-74,999

    • $75-99,999

    • $100-149,999

    • $150,000+

    *Response requiredDo you currently have health insurance?

    • Yes

    • No

    *Response requiredWhich provider are you currently insured with?

    *Response requiredHow long have you been with your current insurance provider?

    • Less than one year

    • One to nearly two years

    • Two to nearly five years

    • Five to nearly ten years

    • Ten years or more

    What type of plan do you have?

    • HMO (Health Maintenance Organization)

    • PPO (Preferred Provider Organization)

    • EPO (Exclusive Provider Organization)

    • POS (Point of Service)

    • High-Deductible Health Plan (HDHP)

    • Catastrophic Plan

    What is your monthly premium?

    *Response requiredDo you feel your current premium is affordable?

    • Yes

    • No

    *Response requiredDoes your current plan cover your family members?

    • Yes

    • No

    • Not applicable

    *Response requiredHave you experienced any coverage gaps or denied claims in the past year?

    • Yes

    • No

    Which of the following services are covered under your current plan?

    • Routine Checkups/Preventive Care

    • Specialist Visits

    • Prescription Drugs

    • Emergency Room Visits

    • Hospital Stays

    • Mental Health Services

    • Maternity Care

    • Vision and Dental

    • Alternative Therapies (e.g., chiropractic, acupuncture)

    *Response requiredI have easy access to the information on my plan(s).

    • Strongly Disagree

    • Disagree

    • Neutral

    • Agree

    • Strongly Agree

    *Response requiredI am satisfied with my current plan.

    • Strongly Disagree

    • Disagree

    • Neutral

    • Agree

    • Strongly Agree

    *Response requiredWhat is your estimated annual medical expense?

    • Less than $1,000

    • $1,000 - $5,000

    • $5,000 - $10,000

    • $10,000 +

    Do you have a Health Savings Account (HSA) or Flexible Spending Account (FSA)?

    • Yes

    • No

    How important is minimizing out-of-pocket costs for you? (1-5 scale)

     
     
    1
    2
    3
    4
    5
    -
    -

    Would you be willing to pay a higher premium for more comprehensive coverage?

    • Yes

    • No

    • Depends on the coverage

    *Response requiredHow much would you be willing to pay for health insurance monthly?

    How would you rate your overall health?

    • Excellent

    • Good

    • Fair

    • Poor

    Do you have any chronic conditions that require ongoing medical care?

    • Yes

    • No

    Do you smoke or use tobacco products?

    • Yes

    • No

    Do you exercise regularly?

    • Yes

    • No

    How often do you use your current health insurance for medical care?

    • Rarely

    • Occasionally

    • Frequently

    *Response requiredHow satisfied are you with the process?

    • Extremely Dissatisfied

    • Somewhat Dissatisfied

    • Neutral

    • Somewhat Satisfied

    • Extremely Satisfied

    Do you anticipate any major medical expenses in the next 12 months (e.g., surgery, childbirth)?

    • Yes

    • No

    • Not sure

    Are you considering changing your current health insurance plan?

    • Yes

    • No

    What are your main reasons for considering a new plan? (Select all that apply)

    • Lower Premiums

    • Better Coverage

    • More Network Options

    • Improved Customer Service

    • Prescription Drug Coverage

    • Maternity or Family Coverage

    Are you open to exploring health insurance plans with different providers?

    • Yes

    • No

    Would you like to receive a customized quote based on your evaluation?

    • Yes

    • No

    Do you have any additional questions or concerns about your health insurance coverage?

    Is there anything else you’d like to share about your health or insurance preferences?