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* 1. Name of contact person?

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* 2. Name of business/organization?

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* 3. Total number of employees?

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* 4. Number of employees in your health plan?

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* 5. Name of your health insurance company?

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* 6. How long have you been insured by this company?

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* 7. How or why did you come to purchase your current plan?

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* 8. What do you/your employees like about your plan?

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* 9. What do you/your employees dislike about your plan?

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* 10. Describe your ideal health plan.

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* 11. Rank these four items in order of importance. When deciding about what health plan to purchase what is most important to you? (Rank from 1-4 with 1 being the most important.)

  1 2 3 4
Benefit Plan Design
Price
Providers
Service

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* 12. Do you have a health insurance agent?

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* 13. If yes, name of agent and agency.

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* 14. Please give us an evaluation of the service/relationship you have with your agent.

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* 15. What healthcare system are you, your employees and their family members using? Please choose all that apply.

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* 16. Would you consider offering a plan that includes only one healthcare system for you, your employees and their family members?

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* 17. If so, which healthcare system would you prefer?

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* 18. Would you consider offering a plan that includes only one healthcare system for you, your employees and their family members if: (Please select all that apply.)

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* 19. Are there other businesses/organizations you know who might have an interest in the Common Ground Healthcare Cooperative?

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* 20. Are there any other comments you would like to provide?

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The information gathered in this survey will be kept confidential.

The information gathered in this survey will be kept confidential.

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