Benefit Census Survey Benefits Census Survey Employee Name * If Craig HomeCare offered an affordable health insurance plan, where would you MOST LIKELY select your coverage from? (You are NOT making a commitment to purchase or waive coverage but if you do not choose the CHC plan and then enroll during open enrollment you may need to complete a health questionnaire at that time). NOTE: If we do select a plan that is considered affordable by ACA standards we will no longer offer the Full Time Bonus of $150/month and you will not be eligible to access any subsidies for plans on the federal exchange. Please keep this in mind when analyzing where you may be accessing coverage effective 3/1/17. Options * Craig HomeCare group plan Through group health plan with another job Through a spouse's or parent's health plan Purchase from Marketplace or other individual plan Insured through Medicare Remain Uninsured OtherOther If you selected that you ARE LIKELY to purchase health insurance through Craig HomeCare, who would you be enrolling? Complete ALL information below for any dependents you MIGHT enroll in the coverage. Please list Dependents. Use the "Add" button at the bottom to add additional dependents. First and Last Name Dependent Type Spouse Dependent 1 Dependent 2 Dependent 3 Dependent 4 Dependent 5 Dependent 6 Dependent 7 Dependent 8 Gender Male Female Date of Birth Zip Code State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Add Remove You must complete the BCBS Health Questionnaire for you and any dependents listed above by December 12th, 2016. To complete the BCBS Health Questionnaire online, please visit Blue Cross Blue Shield and enter the 3 digit code 554. If you would like to receive a paper copy of the Health Questionnaire to complete, please contact HR as soon as possible at 888-260-9990 ext 801. Thank you for your help during this process! Expect to hear from us in early 2017 with further details!
