Insurance Feasibility Questionnaire We are exploring the feasibility of offering group health insurance for our eligible employees. In order to perform the feasibility, we need to know who is interested in taking health insurance if offered through work. Your answers below will help us assess the need. Thank you for your helpName(Required) First Last If offered, would you be interested in getting health insurance under Life Foundation Home Care group health insurance plan?(Required) Yes No Could you help us by telling us why you are not interested in health insurance? Select all that apply I already have insurance I can't afford it Don't wish to answer Do you have dependents that you would include on your plan? Yes No Please provide Dependent Information. Please include all of them, click on + to add more dependents. Only spouse or eligible children can be coveredRelationship (Spouse/Child)First NameLast NameDate of BirthSex (M/F) Add RemoveTerms of Use(Required) I understand that this is not an offer or acceptance of insurance. If insurance is offered and if you are eligible, you will have an opportunity to confirm enrollment at that timeSignature(Required) Reset signature Signature locked. Reset to sign again
