Employee Health Care Survey


Dear Employee: We are looking at healthcare benefit plan designs for our employees. We need to find out about your health insurance coverage. It is very important that we all respond to this survey. Please answer the following questions to guide us on the decisions we will make. Thank you.
Health Insurance:
1. I want to have health insurance coverage through my employer and am willing to share some expense for the cost:
2. I have coverage through my spouse’s (or parents) plan
3. I have coverage through the Federal or State Healthcare Exchange
4. I am willing to pay at least $25 a week for a traditional plan design (this could include HDHP options) that is Employee Only coverage (note: premium contributions will be taken out on a pre-tax basis)
5. I have dependents that I would like to cover for health insurance?
If yes, which dependent(s)
6. Indicate how much additional per week you would be willing to pay for coverage for your dependents:
Thank you for your cooperation!

Leave this empty:

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Signature Certificate
Document name: Employee Health Care Survey
lock iconUnique Document ID: 4d87fc25e39643f2d2db51f17ae068881ba14fd5
Timestamp Audit
September 8, 2020 1:45 pm EDTEmployee Health Care Survey Uploaded by david Levine - david@godentalbrands.com IP 104.139.111.211
September 8, 2020 1:52 pm EDTDavid Levine - david@godentalbrands.com added by david Levine - david@godentalbrands.com as a CC'd Recipient Ip: 104.186.20.224
September 8, 2020 1:57 pm EDTDavid Levine - david@godentalbrands.com added by david Levine - david@godentalbrands.com as a CC'd Recipient Ip: 104.186.20.224