Male
Female


1
2
3
4
5
6
7+


Below $29,000
$29,000 - $70,999
$71,000-$112,999
$113,000 And Over


Got Married
Got Divorced
Loss Of Coverage
Moved
Changed Or Lost Job
Birth Or Adoption
None Of The Above


Cancer
Heart Attack
Stroke
Diabetes
AIDS / HIV
Pulmonary Disease
None Of The Above

Yes No

Yes No

Yes No

Yes No


In The Next Week
In The Next 30 Days
More Than 30 Days From Now
Not Sure


Dental Insurance
Vision Insurance
Life Insurance