Question 1: Long Term Disability Consider a long term disability plan that included the following benefits:
Pays 60% of your gross monthly income.
You can return to work and still receive partial benefits until fully recovered.
The plan would have a better definition of disability than the current Farmers plan.
Based on this information, what is your interest level in hearing more about this plan as a possible alternative to the current Farmers long term disability plan?
Select One
Very interested
Somewhat interested
Not interested
I need more data before deciding.
Question 2: Short Term Disability Consider a short term disability plan that included the following benefits:
Pays 60% of your gross weekly income.
Own-occ definition and a short elimination period.
The plan would have a 3/6 pre-existing condition clause.
Based on this information, what is your interest level in hearing more about this plan as a possible alternative to the current Farmers short term disability plan?
Select One
Very interested
Somewhat interested
Not interested
I need more data before deciding.
Question 3: Comprehensive Vision Plan Consider a vision plan that included the following benefits:
Would not require minimum participation. The current Farmers plan requires at least 2-years participation.
Providers include Wal-Mart, Costco, Eyemasters and other retailers as well as private practice providers.
Based on this information, what is your interest level in hearing more about this plan as a possible alternative to the current Farmers vision plan?
Select One
Very interested
Somewhat interested
Not interested
I need more data before deciding.
Question 4: Dental Plan Consider a dental plan that included the following benefits:
Would not require minimum participation. The current Farmers plan requires at least 1-year participation.
Lower deductibles than the current plan which are $75/$150.
Two plan options – Base and Enhanced – so you can choose the plan that best suits you.
Based on this information, what is your interest level in hearing more about this plan as a possible alternative to the current Farmers dental plan?
Select One
Very interested
Somewhat interested
Not interested
I need more data before deciding.
Demographics Please provide the following information. Completing this data will help us determine the best possible insurance offerings for UFAA. All fields must be completed.
First Name:
Last Name:
Phone:
Email:
Month of Birth:
Select One
January
February
March
April
May
June
July
August
September
October
November
December
Year of Birth:
Select One
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
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1960
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1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
Gender:
Select One
Male
Female
Annual Gross Income:
Select One
$25,000 to $50,000
$50,001 to $75,000
$75,001 to $100,000
$100,001 to $125,000
$125,001 to $150,000
$150,001 to $175,000
$175,001 to $200,000
More than $200,000
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