Employee Health Insurance Questionnaire

An employee health insurance questionnaire can be used to analyse the health insurance policies provided by an employer to an employee and it also helps to know whether the employees are able to derive all the perceived benefits of the health insurance plan, etc.

Sample Employee Health Insurance Questionnaire:

First Name: _______________________ Last Name: _______________________________

Full Address: _______________________________________________________________

Phone Number: ________________________

Email address: _________________________

Age: _____________ Gender: ______

Date of Birth: ___/___/___

Height: _____ feet ___ inches

Weight: _____ lbs

Q1. Please mention the name and address of your health insurance company

Name: ___________________________

Street: _____________ City: ________________ State: ___________ Zip Code: ____________

Q2: Are you currently obtaining medical services from any hospital or a doctor?

a)   Yes

b)   No

Q3: Please mention the policy number of the health insurance policy below


Q4. Please mention the following details regarding your health insurance policy

Start date: ____________ End date: ___________

Q5: Was this health insurance provided by your employer?

a)   Yes

b)   No

Q6. Please mention the premium amount of the health insurance policy


Q7. How often do you have to pay the health insurance premium?

a)   Every month

b)   Every quarter

c)   Every year

Q8: What is the means of providing premium?

a)   By Payroll deduction

b)   By employer

c)   Others, please mention ______________________

Q9. Do you have any acute, chronic, or serious illness?

a)   Yes

b)   No

Q10. If ‘Yes’, please provide the detail of your illness

Illness or Disease: _________________ Treatment: _____________

Q9. Which of the following expenses does your health insurer bear for you?

a)   Hospital stay

b)   Doctor fees

c)   Drugs and medicines

d)   Treatments

e)   Long term nursing

f)    Others, please mention _______________________________

Category: Insurance Questionnaire

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