Your Health Insurance Data
Email
First Name
Last Name
Current health insurance premiums?
Select
Uninsured
$0 employer paid
under $100
Under $200
Under $300
Under $400
Under $500
Under $600
Under $700
Under $800
Under $900
Under $1000
More than $1000
Current deductible
Select
$500
$1000
$1500
$2000
$2500
$3000
$5000
$10000
Uninsured
Have you used tobacco in last 6 months?
No
Yes
Rate health status 1 to 10 (1 being lots of medical challenges 10 being very healthy)
Select
10
9
8
7
6
5
4
3
2
1
Family doctor visits in a normal year?
Select
1-5
6-10
11-15
Over 15
Typical Annual healthcare expenses (exclude premiums)?
Select
$500
$1000
$1500
$2000
$2500
$3000
$3500
$4000
More
Number of monthly prescriptions?
Select
None
1
2
3
4
5 or more
Do you have access to group health?
Yes
No
How many people in your household:
Select
1
2
3
4
5
6
7
8
more
Household Income:
Select
$0-$15,000
$15,000-$25,000
$25,000-$50,000
$50,001-$75,000
$75,001-$100,000
$100,001-$125,000
$125,001-$150,000
$150,001-$175,000
More than $175,000
Not interested in ACA (Obamacare)
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