SG Website: Weight Loss Drug Survey

1

Are you a former or current employee of U.S. Bank?* This field is required.

Current

Former

No

2

If former employee, did you work for U.S. Bank sometime within the past 5 years?* This field is required.

Yes

No

3

Do you smoke or vape?* This field is required.

Yes

No

4

Did you formerly or 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

5

Thank you! Based on your responses, it appears that you may qualify for compensation!

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.

6

What is your first and last name?* This field is required.

First Name

Last Name

7

What is your email?* This field is required.

example@example.com

8

What is your phone number?* This field is required.

Please enter a valid phone number.

9

Please verify that you are human* This field is required.