PAII Health Insurance Questionnaire Survey for PAI Innkeeper Members.

1

I need health insurance... YES | NO

2

Do you have full time employees to whom you would like to offer health insurance ?
None | 1-2 | 3-5 | 6-10 | 10 or more

Owner Info

2a

Owner(s) Age and Sex:
We have Owner Males between the ages of 18 -25 years of age

2b

We have Owner Females between the ages of 18 -25 years of age

2c

We have Owner Males between the ages of 26 and 39 years of age

2d

We have Owner Females between the ages of 26 and 39 years of age

2e

We have Owner Males between the ages of 40 and 50 years of age

2f

We have Owner Females between the ages of 40 and 50 years of age

2g

We have Owner Males between the ages of 51 and 60 years of age

2h

We have Owner Females between the ages of 51 and 60 years of age

2i

We have Owner Males between the ages over the age of 61

2j

We have Owner Females between the ages over the age of 61

 

2j

Employee Ages and Sex:
We have Males between the ages of 18 -25 years of age

2l

We have Females between the ages of 18 -25 years of age

2m

We have Males between the ages of 26 and 39 years of age

2n

We have Females between the ages of 26 and 39 years of age

2o

We have Males between the ages of 40 and 50 years of age

2p

We have Females between the ages of 40 and 50 years of age

2q

We have Males between the ages of 51 and 60 years of age

2r

We have Females between the ages of 51 and 60 years of age

2s

We have Males between the ages over the age of 61

2t

We have Females between the ages over the age of 61

2u

We have part time employees (regularly working fewer than 30 hours per week?)

3

Do you currently have heath insurance from an provider ? Yes | No

3a

If YES to #3 above, from whom do you purchase your current health insurance ?
Local Agent / Broker With employment Local Association
CVB Other, Please explain
     
   

3b

If YES to #3 above, what type of health insurance do you currently have ?
 
HMO PPO Blue Cross / Blue Shield
Supplemental Medicare Medicare Supplemental
Major Medical Only Other, please explain:
 
 
 
   
 3c If YES to #3 above, how much do you pay per month / per person?
   
Less than $75 $101-$150 $201-$250 $300 or more
$76-$100 $151-$200 $251-$300  
 
 
 
   

 

4

Which items below are most important to you in choosing a health insurance plan ? Please rank all in order of importance. Select 1 next to the most important item, "2"next to the second most important item, etc. You will only be able to use one number once...
 
Broadest choice of physicians and hospitals

Most

1

2

3

4

5

6

7

Least

Coverage for specific medical conditions

Most

1

2

3

4

5

6

7

Least

Good customer service from insurer

Most

1

2

3

4

5

6

7

Least

Low deductibles and / or co-payments

Most

1

2

3

4

5

6

7

Least

Low employee share of premium

Most

1

2

3

4

5

6

7

Least

Low employer share of premium

Most

1

2

3

4

5

6

7

Least

Simple administration and forms

Most

1

2

3

4

5

6

7

Least

 

5

In which state are you legally domiciled ?
   

6

What other factors do you consider important when choosing whether to offer a health insurance plan, please comment...

7

Your email address please ?
Your email address again please ?