Health Insurance Coverage Survey Template

Health Insurance Coverage Survey Template offers questions and examples on the quality of a respondent's current healthcare provider. This sample can be edited by the survey maker according to the required details about the health insurance coverage. Some of the question examples of this questionnaire are demographical such as "What is your age?", "What is your family's annual income?" or "What is your marital status?" et al.


Please take a few minutes to fill out this survey on health insurance coverage. We value your feedback and your responses will be used to serve you better. Thank you for your input.


Please provide us with the following information.

1. What is your gender?
4. What is the highest level of education you have attained?
5. What is your marital status?
6. Are you disabled?
7. Please mark your annual gross income?
8. Which of the following group of race best describes you?
9. Which health coverage are you currently enrolled with?
10. How difficult is it for you to pay health insurance cost?
11. Do you have a child 26 years and below that you have been unable to include in your coverage?
12. Has any of your family members been dropped out of coverage after a diagnosis of some illness?
13. Has lack of health insurance cover made you consider one of the following?

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