Health Insurance Survey Question Title * 1. Name Question Title * 2. Do you currently have health insurance? Yes No Question Title * 3. If so, are you covered by your spouses employer or did you purchase on your own? Spouse employer On my own N/A Question Title * 4. If you are currently covered, who is the insurance carrier? Question Title * 5. If you currently do not have health insurance, would you want health insurance coverage if we offered it? Yes No N/A Other (please specify) Question Title * 6. Would you enroll your whole family? Yes No Spouse only children only N/A Other (please specify) Question Title * 7. Would you enroll in dental and/or vision, if offered? Yes No Dental only Vision only N/A Question Title * 8. Any questions, please list below Done
