This free survey is powered by
  1. Surveys
  2. 2017
  3. April
  4. H
  5. Health Insurance
Questions marked with a * are required Exit Survey
 
1. Contact Information
* First Name : 
* Last Name : 
Address 1 : 
Address 2 : 
City : 
State : 
Zip : 
* Phone : 
* Email Address : 
Country : 
 
 
 
2. Choose a Health Insurance Plan
 
Basic
 
Premium
 
Full Coverage
 
 
 
3. What types of Debit Card Payment
 
Visa
 
Mastercard
 
 
 
4. What is your date of birth?
MonthDayYear
  
 
 
 
5. Gender
 
Male
 
Female
 
 
 
6. Highest level of education
 
Primary
 
Secondary
 
Tertiary
 
 
 
7. Income type 
 
Student
 
Worker
 
Business
 
 
 
* 8. Job Type
   
 
 
 
9. Marital Status
 
Single
 
Married
 
Divorced
 
 
 
10. Physical Build
 
Athletic
 
Slim
 
Plus size
 
Obese
 
Share This Survey:          Online Survey Software Powered by  QuestionPro Survey Software