WHG Benefits Request

Watson Health Group Benefits Request Form
Household Information
What's your name?
Height
Weight
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is there anyone else applying for coverage?
Additional family members information
Enter Name, Date of Birth, Height, Weight, and Gender for each additional family member.
Entire household income
How would you describe your current coverage situation?

Other (please specify)
Do you currently have government coverage?
Have any of these happened recently?
How soon are you hoping to get something in place?
When it comes to your health coverage, how are you feeling right now?There's no wrong answer — just want to make sure I understand where you're coming from.
What feels like the biggest challenge with your coverage right now?
Which part feels hardest to deal with right now?
If you've been putting this off, what's been getting in the way?
What matters most to you in a plan?

Other (please specify)
What's the main thing you'd change if you could fix one part of your health coverage, if anything?
Which trade-off would you be most comfortable making?

Other (please specify)
How important is protecting your income/ financial wellbeing when a medical emergency occurs?
When a medical emergency occurs, how long could you be off work before you would run into a financial issue?
How important is keeping your current doctors and prescriptions?
Please add any Doctors and or prescriptions that need to be covered under your healthplan.
What questions have been on your mind that nobody has answered yet?
Should be Empty:

Watson Health Group Benefits Request Form

Household Information