1. Do you currently have health insurance?

• Yes
• No (skip to question 12)

2. What kinds of health insurance do you have?

• Medical
• Vision
• Dental

Please type the remaining answers to the previous question. If you have other types of insurance (beyond medical, vision, or dental) please list as well.

3. What is the name of your insurance company? If you have more than one company please list all companies:

4. Do you have single coverage or family coverage? *

• Single
• Family

If you have something other than single or family coverage, what is it?

5. Do you have health insurance through your employer?

• Yes
• No

6. Are you employed, but your employer does not provide health insurance?

• Yes
• No

7. My insurance coverage will pay for most of the following:

• Hospitalization
• Visits to specialists
• Prescription drugs
• Routine doctor's visits
• Home health care
• Pregnancy and maternity care
• Birth control
• Tests such as blood, CAT scans and MRIs
• Mental health

Please type all the remaining types of coverage you have from the previous question.

8. How well do you understand your insurance plan?

• Very well
• Well
• Not well
• Not at all
• No opinion

9. If you have insurance through your employer, did they give you a choice of coverage?

• Yes
• No

10. Do you feel happy with your insurance coverage?

• Yes
• No

11. The main problem I have with my insurance coverage is:

• Deductible too high
• Premium too high
• Can't go to the doctor I want
• Won't pay for major medical problems
• Won't pay for prescriptions
• Won't cover certain things I need
• Won't cover family members
• Too expensive for family members to join
• Other

please explain

12. The reason that I cannot get insurance is:

• Too expensive
• Employer has plan, but I only work part-time
• Don't need insurance
• Too sick
• Past illness/medical history
• High risk
• Age
• Don't know how to get insurance
• Other

please explain

13. I have been turned down from the following company or companies and I feel like their practices should be regulated or investigate:

14. Is there anything else you think we should know about health insurance?

15. Do you have unpaid medical bills?

• Yes (please indicate the amount below)
• No

16. Approximately how much unpaid medical debt do you currently have?

• Less than $1,000
• $1,000 to $5,000
• $5,000 to $10,000
• $10,000 to $20,000
• Over $20,000
• I don't know

Would you like to sign up to be a member of the campaign for health care?

• Yes I would like to be invited to events
• No thank you

Would you like to volunteer?

• Yes, please contact me about volunteer opportunities
• No thank you