What is your organization's name?

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* 1. What is your organization's name?

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

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

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

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

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.

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* 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.

What is your full name?

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* 5. What is your full name?

What is your title?

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* 6. What is your title?

What is your e-mail address?

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* 7. What is your e-mail address?

What is your organization's phone number?

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

What is your organization's FAX number?

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

Are you currently a KNN member?

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* 10. Are you currently a KNN member?

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.

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* 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.

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

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

Are you interested in a group health plan?

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

Who is your current health insurance carrier?

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* 14. Who is your current health insurance carrier?

What is your current health insurance plan renewal date?

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

Please enter a date...
Are you interested in a group dental plan?

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

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

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

Are you interested in supplemental benefits?

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* 18. Are you interested in supplemental benefits?

If interested in supplemental benefits, which benefits?

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

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

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

Do you have any other comments, questions, or concerns?

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

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