Health Coverage Survey Question Title * 1. Do you currently have health insurance for yourself and/or family? Yes No Other (please specify) Question Title * 2. If you are a business owner, do you offer health insurance to employees? Yes No Not Applicable Question Title * 3. If you have health insurance, is it a: High Deductible Health Plan Catastrophic Plan Other (please specify) None of the above Question Title * 4. If you are either not insured, have a high deductible or catastrophic plan, would you be interested in a primary care program for a monthly fee? (to include up to 30 visits/year for $50/month with the option to be covered by individual or employer) Yes No Not applicable Question Title * 5. If you are interested in the program would it be for: Yourself only You and your family Question Title * 6. If interested in learning more about a primary care program or exploring other healthcare options, please leave your contact info below: Name Company Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Done