COABE is always looking for new and exciting membership benefits! Many of our members report working part time jobs without benefits, and so we have begun the process of exploring offering a health, dental, and life term insurance program to our members. We are in the beginning stages of talks with some of the larger health carriers and need to gather a little information to ensure we can provide our members with the most competitive rates. Please take a couple minutes to answer the questions below.

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* 1. Please indicate your current employer.

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* 2. Please indicate your current health plan carrier (If none, please indicate none).

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* 3. Please indicate your current health care coverage (if none, please indicate none).

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* 4. Please indicate your Employer Premium Contribution (if not known, please indicate "not known"):

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* 5. Does your employer contribute to your deductible?  If so, please indicate the percentage. If you do not know, please indicate "not known":

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* 6. Please indicate your age:

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* 7. Please indicate your gender.

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* 8. Please indicate your zip code.

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* 9. Please indicate the size of your household:

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* 10. Do you have current membership with COABE?

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* 11. If you have current membership with COABE, is it provided through a group membership or did you purchase an individual membership?

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* 12. Please check the box(es) to indicate the benefits you are interested in.

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