First name *
Last name *
Phone Number *
Work email (where you received the invite for this form) *
How long have you been with the organization? *
— Select —
<1 month
1-3 months
4-6 months
6-9 months
9-12 months
1 year+
Are you currently... *
— Select —
Single no children in the household (no children or all over 25)
Single with children in the household (25 or younger)
Married no children in the household (no children or all over 25)
Married with children in the household (25 or younger)
Other:
What is your current health insurance plan? *
— Select —
Individual major medical insurance
Covered by spouse/partner
Healthshare Plan
COBRA
No insurance
Family major medical through my work
Other
What is the #1 thing that an insurance provider could do to better serve you and your family? Please be specific and feel free to get creative, as we are trying to build the best benefits in the world for you! List out what would be meaningful to you and your family - we are listening. *
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