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PAII Health Insurance Questionnaire Survey
for PAI Innkeeper Members. |
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1 |
I need health insurance...
YES |
NO
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2 |
Do you have full time employees to whom you would like to
offer health insurance ?
None |
1-2 |
3-5 |
6-10 |
10 or more
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Owner Info
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2a |
Owner(s) Age and Sex:
We have
Owner Males between the ages of 18 -25 years of
age |
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2b |
We have
Owner Females between the ages of 18 -25 years of
age |
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2c |
We have Owner Males between the ages of 26 and 39 years of
age |
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2d |
We have Owner Females between the ages of 26 and 39 years
of age |
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2e |
We have Owner Males between the ages of 40 and 50 years of
age |
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2f |
We have Owner Females between the ages of 40 and 50 years
of age |
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2g |
We have Owner Males between the ages of 51 and 60 years of
age |
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2h |
We have Owner Females between the ages of 51 and 60 years
of age |
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2i |
We have Owner Males between the ages over the age of 61 |
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2j |
We have Owner Females between the ages over the age of
61 |
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2j |
Employee Ages and Sex:
We have Males between the ages of 18 -25 years of age |
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2l |
We have Females between the ages of 18 -25 years of
age |
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2m |
We have Males between the ages of 26 and 39 years of
age |
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2n |
We have Females between the ages of 26 and 39 years of
age |
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2o |
We have Males between the ages of 40 and 50 years of
age |
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2p |
We have Females between the ages of 40 and 50 years of
age |
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2q |
We have Males between the ages of 51 and 60 years of
age |
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2r |
We have Females between the ages of 51 and 60 years of
age |
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2s |
We have Males between the ages over the age of 61 |
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2t |
We have Females between the ages over the age of
61 |
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2u |
We have part time
employees (regularly working fewer than 30 hours per week?) |
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3 |
Do you currently have heath insurance from
an provider ?
Yes |
No
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3a |
If YES to #3 above, from whom do you
purchase your current health insurance ?
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3b |
If YES to #3 above, what type of
health insurance do you currently have ? |
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| 3c |
If YES to #3 above, how much do you
pay per month / per person? |
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4 |
Which items below are most important
to you in choosing a health insurance plan ? Please rank all in
order of importance. Select 1 next to the most important item, "2"next to the second most
important item, etc. You will only be able to use one number
once... |
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| Broadest choice of
physicians and hospitals |
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Most |
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Least |
| Coverage for
specific medical conditions |
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Most |
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Least |
| Good customer
service from insurer |
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Most |
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Least |
| Low deductibles and
/ or co-payments |
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Most |
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Least |
| Low employee share of premium |
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Most |
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Least |
| Low
employer share of
premium |
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Most |
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Least |
| Simple
administration and forms |
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Most |
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Least
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5 |
In which state are you legally domiciled ?
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6 |
What other factors do you consider important when choosing whether to
offer a health insurance plan, please comment...
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7 |
Your email address please ? |
| Your email address again please
? |
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