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
Street: _____________ City: ________________ State: ___________ Zip Code: ____________
Q2: Are you currently obtaining medical services from any hospital or a doctor?
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?
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?
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
e) Long term nursing
f) Others, please mention _______________________________
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