Group Health Insurance Questionnaire

1

Name* This field is required.

2

Position at Organization* This field is required.

3

Name of Organization* This field is required.

4

Email* This field is required.

5

How many individuals do you wish to insure?* This field is required.

6

0 -17

18-24

25-30

31-40

41-60

Over 60

7

How many individuals are Mexican citizens?* This field is required.

8

How many individuals are Foreigners?* This field is required.

9

Do you have an existing group plan?* This field is required.

Yes

No

10

Why are you looking for a new plan?* This field is required.(Please check all that apply)

Current plan is too expensive

Issues with claims

Issues with service

Want to compare other offers

Want more health benefits

11

What is the name of company?* This field is required.

12

Why are you looking for a new plan?* This field is required.(Please check all that apply)

Current plan is too expensive

Issues with claims

Issues with service

Want to compare other offers

Want more health benefits

13

What type of organization?* This field is required.

Mexican for-profit

Mexican non-profit

Missionary group

Consultancy working in Mexico

14

How soon do you want to purchase a group plan?* This field is required.

Date

15

When does your group plan expire?* This field is required.

Date

16

Which of the following benefits are important to include in your Group Plan? (Please check all that apply)* This field is required.

Mexico-only coverage

International coverage

Vision & Dental Coverage

Annual Exams

Maternity

Disability insurance

Travel Assistance

17

Additional Comments

18