Survey for Double Coverage

Wasted Dollars

Survey for Double Coverage

The following is a questionnaire that all employees are required to complete and return to ________ by ___/___/___.
There are several reasons for this survey.

(1) To determine how much medical premium is not being used due to double coverage.
(2) To make sure all of our employees and dependents have medical coverage and if not, why.
(3) New company policy may be determined due to the results of this survey.

Please note that intentionally false information can be reason for termination of employment. Questions can be directed to _________ phone number ___________ email__________. Your survey will remain confidential. Thank you for your mandatory participation.

(Circle your answers)

1.) Are you currently covered under our medical plan? (If no, go to question 8)	Yes	No
2.) Do you have a spouse?	Yes	No
3.) Do you have dependent children? If yes, how many ____?	Yes	No
4.) If you have a spouse, is your spouse covered under our medical plan?	Yes	No
5.) Is your spouse eligible for other group medical insurance through an employer?	Yes	No
6.) If question 5 is yes, is your spouse covered under that employers' medical plan?	Yes	No

7.) Check who does not have medical coverage anywhere. ___ Yourself ___ Spouse ___ Children

8.) If you or anyone in your family is not covered under any medical insurance at this time, please tell us the reason why you or your dependents are not covered under any medical insurance.

_______________________________________________________________________

Name _____________________________ Date ________

Please print this survey and use for your own convience, then click on the in the upper right corner to close this window and continue