* 1. What is your organization's name?

* 2. What is your organization's physical address (if different from mailing address)? Please include City, State & Zip Code.

* 3. What is your organization's mailing address? Please include City, State & Zip Code.

* 4. What county are you located in ? These counties are not eligible for the health plan (Bullitt, Hardin, Jefferson, Oldham, Shelby, Spencer & Trimble).  However, all counties are eligible for the dental and supplemental benefits.

* 5. What is your full name?

* 6. What is your title?

* 7. What is your e-mail address?

* 8. What is your organization's phone number?

* 9. What is your organization's FAX number?

* 10. Are you currently a KNN member?

* 11. How many full-time eligible employees (working 30 or more hours/week) work for your organization?  NOTE: at least two eligible employees are required to enroll for there to be a group plan.

* 12. How many part-time employees (work less than 30 hours per week) work for your organization?

* 13. Are you interested in a group health plan?

* 14. Who is your current health insurance carrier?

* 15. What is your current health insurance plan renewal date?

Please enter a date...

* 16. Are you interested in a group dental plan?

* 17. How many employees are currently enrolled in your health insurance plan?

* 18. Are you interested in supplemental benefits?

* 19. If interested in supplemental benefits, which benefits?

* 20. How soon are you interested in learning more about the KNN benefits?

* 21. Do you have any other comments, questions, or concerns?