Health Benefits Feedback Form
Please share your feedback about your health benefits experience to help us improve our offerings.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
What is your relationship to the health benefits program?
*
Employee
Dependent/Family Member
Retiree
Other
Which of the following health benefits have you used in the past 12 months? (Select all that apply)
*
Medical Insurance
Dental Insurance
Vision Insurance
Mental Health Services
Wellness Programs
Prescription Coverage
Other
How often do you use your health benefits?
*
Frequently (monthly or more)
Occasionally (a few times a year)
Rarely (once a year or less)
Never
Please rate your satisfaction with the following aspects of your health benefits.
*
Rows
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
Coverage Options
1
2
3
4
5
Cost/Value
6
7
8
9
10
Ease of Access
11
12
13
14
15
Customer Service
16
17
18
19
20
Claims Process
21
22
23
24
25
How easy is it to understand your health benefits information and coverage?
*
Very Difficult
1
2
3
4
Very Easy
5
1 is Very Difficult, 5 is Very Easy
How would you rate the overall impact of your health benefits on your health and wellbeing?
*
1
2
3
4
5
What improvements would you like to see in your health benefits?
Please share any additional comments or feedback.
What is your age group?
Please Select
Under 25
25-34
35-44
45-54
55-64
65 or older
Prefer not to say
Submit Feedback
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