| Name * |
|
| Date * |
|
| Phone Number * |
Day
Evening
|
| Email Address * |
|
| What company do you work for? * |
|
| What county do you live? * |
|
| Age * |
|
| How long have you worked for this employer? * |
|
How many hours a week do
you work? * |
per week |
| Are you: * |
Full Time
Part time
Seasonal
Self Employed |
| Do you work anywhere else? * |
Yes
No |
Where? |
| Do you currently have health insurance? * |
Yes
No |
| If you had/have insurance, when was the last time you had health insurance? (year) * |
|
| Are you married? * |
Yes
No |
| If Yes, is your spouse employed? |
Yes
No |
If Yes, does his/her employer offer
healthcare insurance? |
|
What is your spouse’s estimated
annual income (before taxes)? |
|
| Do you have? * |
Medicaid
Medicare
VA Medical Benefits
None |
| If you do not have health insurance, are you interested in buying low cost health care coverage for you or your family with your Employer’s assistance? * |
Yes
No |
What is your annual combined family income before taxes? *
Please include your spouse’s income, alimony, social security income, etc. Your family size includes yourself, your children and/or your spouse living with you.
Please place a check next to the annual family income for you & your family. |
Family Size |
Max. |
Yes, family income = this amount or less |
No, family income = more than this amount |
| 1 |
$ 21,660 |
Yes |
No |
| 2 |
$ 29,140 |
Yes |
No |
| 3 |
$ 36,620 |
Yes |
No |
| 4 |
$ 44,100 |
Yes |
No |
| 5 |
$ 51,580 |
Yes |
No |
| 6 |
$ 59,060 |
Yes |
No |
| 7 |
$ 66,540 |
Yes |
No |
| 8 |
$ 74,020 |
Yes |
No |
| |
|
| Type in your name as signature * |
|
The above signature certifies that the information provided to Tri County Project Care Inc., for the purpose of participation in the program is correct to the best of my knowledge and authorizes release of any information request in regard to certification.
Thank you for completing this survey. Your information will be kept confidential. Questions or comments? Call us at 843-388-9719.
|