The Illinois Academy of Family Physicians is exploring an opportunity to offer group health insurance to our members, their families and staff. Please fill out the survey below to assess the interest of our members in this service. You will not be contacted by any group health insurance agent based on your response.

Physician or Group Name: _____________________________

Office Contact: _____________________________________

Office Number: _____________________________________

 

Would you be interested in obtaining a quote for a group health insurance sponsored by IAFP for yourself, your family and/or employees?

Yes ____

No ____

If yes, for what types of group health plan designs would you be interested in seeing quotes?

PPO ____

High deductible plan with HSA ___

Other (please explain) ____________________________

Please check the ancillary lines of coverage you would like to see quotes for:

Life & Accidental Death & Dismemberment
 Insurance ____

"Own Specialty/Sub-Specialty" Long Term Disability for Physicians ___

Long Term Disability for staff ___

Short Term Disability___

Dental Insurance___

Please fax your responses back to 630-435-0433 attention Jennifer O'Leary or mail to:

Jennifer O'Leary
IAFP
4756 Main Street
Lisle, IL 60532