Association Health Plan Interest Survey

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* 1. What year were you born?

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* 2. Gender

Male

Female

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* 3. What is your home zip code?

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* 4. Select the tax filing status you currently hold

Contractor (1099)

W2 Employee

Managing Broker

Sole Proprietorship/Partnership

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* 5. If you're a managing broker, list the number of each in your agency. Place a '0' in the N/A space if this question doesn't apply to you.

1099 Agents

W2 Employees

N/A

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* 6. Select your annual gross income range

0 to 24,999

25,000 to 49,999

50,000 to 74,999

75,000 to 99,999

100,000 to 124,999

125,000 to 149,999

150,000 to 174,999

175,000+

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* 7. How do you currently obtain health insurance?

Individual policy (federal marketplace, state marketplace, or local agency)

Spouse/dependent coverage

Your employer

Not insured

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* 8. If you have health insurance, what type of coverage do you have?

Individual

Individual plus spouse

Individual plus children

Family

N/A

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* 9. Indicate your level of interest in participating in group purchase of medical, dental, vision, and other benefits for your association assuming the cost is reasonable

Extremely interested

Very interested

Somewhat interested

Not at all interested

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* 10. Check all of the products you'd be interested in purchasing through your association assuming the cost is reasonable

Dental/vision insurance

Life insurance

Long-term disability insurance

Long-term care insurance

Retirement plans

Supplemental insurance (accident, cancer, critical illness, hospital indemnity, etc.)