QUESTIONNAIRE
NO: DATE:
NAME:
ADDRESS:
SOCIAL ECONOMIC FACTORS
1. Gender of the respondents
Male
Female
2. Age of the respondents
Below 25
25-34
35-44
45-54
55-64
Above 65
3. Educational Status of the respondents
Primary School
High School
High secondary
Degree
Professional
Others
Illiterate
4. Marital Status of the respondents
Married
Unmarried
5. Occupation Information of the respondents
Salaried
Professional
Self Employed
Business
Retired
6. Gross Income of the respondents
Below 50000
50000 – 100000
100000 – 200000
200000 - 300000
300000 – 400000
400000 - 500000
500000 – 1000000
Above 1000000
7. Do you aware of Health Insurance Plans
Yes
No
8. Do you have Health Insurance Plan
Yes
No
9. How do you know about Health Insurance
Insurance Agents
Marketing Sales Managers
News Paper
Television / Radio Advertisement
Family / Friends
Hospitals
10. In which company you would like to purchase Health Insurance Plan
Government Health Insurance
Public Ltd Health Insurance company
Private Health Insurance Company
Foreign based / MNC Health Insurance
11. Particular reason behind choosing Health Insurance Plan
Brand Name
Safety
Good Customer Service
Good Claim Processing
12. Purpose of taking Health Insurance Plan
Covering Medical Expenses
Tax Purpose
Others
Compulsion
13. What would you like more in Health Insurance policy
Better Utilization of health care facility
Easy reimbursement process
Emergency Health care
Reduce cost of drugs expenditure
14. Benefits of taking Health Insurance Policy
Compensation
Accident & Permanent Disability
Benefits
Provides free of cost – Major surgeries
Critical illness benefits
Others
No idea
15. Do you think your Health Insurance premium rates are reasonable
YES
NO
16. How happy are you with the choice of Health care providers in your current plan
Highly Satisfied
Satisfied
Not Satisfied
17. How satisfied are you with the outcome of your claims
Highly Satisfied
Satisfied
Not Satisfied