SG Website: Weight Loss Drug Survey

1
Do you smoke or vape?* This field is required.
Yes
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2
Do you currently or did you formerly get health insurance coverage via your employer?* This field is required.
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3
Are you a current or former employee?* This field is required.
Current Employee
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4
If you are a former employee, did you pay the surcharge, extra fees or higher premium within the past 3 years?* This field is required.
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5
If you are a former employee, did you work for the company in question sometime within the past 3 years?* This field is required.
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6
Do you currently pay a nicotine surcharge or extra fees or a higher premium for coverage because you smoke or vape?* This field is required.
Yes
No
7
Please list the name of the company you are contacting us about.* This field is required.
8
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There is no out-of-pocket cost for representation. If you would like to speak to one of our representatives to learn more, please submit your contact information on the next screens.
9
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10
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11
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13
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