We are currently reviewing health and dental insurance renewal options with our insurance provider as well as bids from other insurance carriers to offer the best and most cost-effective insurance coverage to our employees. Your feedback is important in this process. Please take a few minutes to complete this survey and return it to human resources by [date].
Are you currently enrolled in [Company Name]'s group health insurance plan? ☐ Yes ☐ No
If no, please complete this section:
☐ I have coverage elsewhere.
☐ I cannot afford coverage at this time.
☐ Coverage is affordable but not elected.
If yes, please continue with the full survey.
Coverage elected:
☐ Employee only
☐ Employee + Spouse
☐ Employee + Children
☐ Family
Plan selected:
☐ [Carrier name] [Type of plan (HMO, Open access, PPO, etc.)]
☐ [Carrier name] [Type of plan (HMO, Open access, PPO, etc.)]
☐ [Carrier name] [Type of plan (HMO, Open access, PPO, etc.)]
Are you currently enrolled in [Company Name]'s dental insurance plan? ☐ Yes ☐ No
If no, please complete this section:
☐ I have coverage elsewhere.
☐ I cannot afford coverage at this time.
☐ Coverage is affordable but not elected.
If yes, please continue with the full survey.
Coverage elected:
☐ Employee only
☐ Employee + Spouse
☐ Employee + Children
☐ Family
Using a scale of 1-5, with 5 being strongly agree and 1 being strongly disagree, please select one response for each statement.
| | | | | | | |
|---|---|---|---|---|---|---|
| Health Insurance | 5 | 4 | 3 | 2 | 1 | N/A |
| I am happy with the network of doctors/hospitals through the current provider. | ° | ° | ° | ° | ° | ° |
| The cost of health insurance premiums (paycheck deductions) is affordable. | ° | ° | ° | ° | ° | ° |
| Out-of-pocket costs (deductible, office co-pays, co-insurance, prescription co-pays) are reasonable. | ° | ° | ° | ° | ° | ° |
| I don't know where to turn for customer service support or claims questions. | ° | ° | ° | ° | ° | ° |
| Insurance claims are processed timely. | ° | ° | ° | ° | ° | ° |
| I understand the different health insurance plan options available to me. | ° | ° | ° | ° | ° | ° |
| I am satisfied overall with the current health insurance carrier. | ° | ° | ° | ° | ° | ° |
Comments or suggestions for improvement: | ||||||
Using a scale of 1-5, with 5 being strongly agree and 1 being strongly disagree, please select one response for each statement.
| Dental Insurance | 5 | 4 | 3 | 2 | 1 | N/A |
| I am happy with the network of dentists through the current provider. | ° | ° | ° | ° | ° | ° |
| The cost of dental insurance premiums (paycheck deductions) is affordable. | ° | ° | ° | ° | ° | ° |
| Out-of-pocket costs (deductible, office co-pays, co-insurance) are reasonable. | ° | ° | ° | ° | ° | ° |
| I don't know where to turn for customer service support or claims questions. | ° | ° | ° | ° | ° | ° |
| Insurance claims are processed timely. | ° | ° | ° | ° | ° | ° |
| Child orthodontics is an important coverage option on the dental plan. | ° | ° | ° | ° | ° | ° |
| I am satisfied overall with the current dental insurance carrier. | ° | ° | ° | ° | ° | ° |
Comments or suggestions for improvement: | ||||||
If available, I would be interested in electing the following supplemental benefits at my own cost:
☐ Additional long-term disability coverage for myself.
☐ Additional short-term disability coverage for myself.
☐ Long-term care for dependents and/or myself.
☐ Additional life insurance for family members and/or myself.
☐ Cancer insurance, accident policy, hospital indemnity plan.
☐ Pet insurance.
☐ Other: ________________________________________.
Additional comments or suggestions:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Optional:
Date: ___________ Employee name: __________________________
Department: ______________________________________________
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