Health Plan Questionnaire

Directions

Please provide us with your full name. Your name will be printed on the information that is returned to you.

Full Name

For each of the 15 questions below select either "a" or "b" to indicate your answer. Please choose only one answer for each question. If both "a" and "b" seem to apply to you, choose the one that applies more frequently. When you are finished selecting answers to each question please select the submit button at the end of the form.

1. I prefer to have a
     (a) lower deductible
     (b) higher deductible

2. My ideal plan would
     (a) cost less with less benefits
     (b) cost more with more options

3. I have enough money to cover a large deductible
     (a) no
     (b) yes

4. Doctor visit coverage for when I am sick is
     (a) important to me
     (b) not important, I don't get sick

5. Is prescription coverage important to you?
     (a) yes
     (b) no

6. If I had my choice I would choose
     (a) lower premium
     (b) prescription coverage

7. Which is most important to you?
     (a) doctor visits
     (b) lower premium

8. How do you feel about good discount plans for doctor visits and prescription coverage?
     (a) I don't like discount plans
     (b) If I can save more, why not!

9. I am afraid of getting a critical illness disease like cancer, heart attack, stroke, etc....
     (a) yes
     (b) no

10. What option fits you more closely?
      (a) a plan that has a 5 million dollar max-this plan has a higher premium
      (b) a plan that covers everything up to 100,000 per incident(the probability of a person reaching 100K is .04%)-this plan has a lower premium

11. I
      (a) have children
      (b) do not have children 

12. Dental coverage is
      (a) important to me
      (b) what teeth? 

13. I am
      (a) a risk taker
      (b) conservative

14. I am
      (a) age 27 or below
      (b) somewhere above 27 

15. Holistic health is
      (a) the best
      (b) what's Holistic?

When you have completed filling out the above form please click on the Submit button below. Your results will be returned to you. If you are not satisified with your answers above please click on Reset to clear the form.

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