Medical Insurance Survey

OPTIONAL:  Please let us know who you are and where you teach:

First Name
Last Name

College	Choose from the list below Arts and Sciences College of Education Chicago College of Performing Arts Walter E. Heller College of Business Administration Evelyn T. Stone University College
School (if in Arts and Sciences)	Choose from the list below Communication Computer Science and Telecommunications Liberal Studies Policy Studies Psychology Science and Mathematics

THE SURVEY

1. Are you interested in a health savings account, which belongs to you and is portable?

   Choose Yes or No in the drop-down box. Yes No

2. Do you currently have medical insurance coverage from any source on:

   Yourself:	Choose Yes or No in the drop-down box. Yes No
   Spouse/Partner:	Choose Yes, No, or N.A. in the drop-down box. Yes No Not Applicable
   Dependent Children:	Choose Yes, No, or N.A. in the drop-down box. Yes No Not Applicable

3. What is the primary source of this medical coverage?

   Make your choice from the drop-down box. Another employer Former employer (retiree or ex-employee) Spouse/partner’s employer Medicare Kidcare / Family Care (Illinois state program) Individual health insurance Other Not applicable (no insurance)

4. What is your monthly cost or contribution?

   For you only
   For you and your family

5. What is your estimated total annual out of pocket expense for medical (include contributions, copayments, deductibles, coinsurance, and items not covered by insurance).

   Make your choice from the drop-down box. Under $1,000 $1,000 - $1,999 $2,000 - $2,999 $3,000 - $3,999 $4,000 - $4,999 $5,000 or more

6. Comments or suggestions: