1) Fermilab ID number:
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2) Name of home institution:
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| 3) Position at institute: |
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If other please specify:
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| 4) Date of Birth (MM/DD/YY): |
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| 5) Gender: |
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6) Illinois Zip code while resident at the lab:
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| 7) Name of current Medical Insurance Carrier: |
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If other please
specify:
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| 8) Type of medical insurance you currently have: |
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If other please
specify:
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| 9) Type of medical insurance coverage: |
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| 10) If family coverage specify type and number of
dependents: |
| spouse |
| children |
If children: How
many ?
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11) Cost of monthly insurance premium (US dollar):
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| 12) Who pays the premium ? |
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If other please
specify:
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| 13) Are you satisfied with your insurance coverage
? |
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| 14) If you are not satisified, check all that apply: |
| cost of premium |
| selection of
primary care physicians in area local to Fermilab |
| type of insurance plan that is
available (HMO, PPO, etc) |
| does not provide
prescription drug coverage |
| does not
provide for non-emergency care |
| only limited
coverage available when resident in Fermilab area |
| other |
If other please
specify:
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| 15) Do you have a social security number ? |
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| 16) Are you a US citizen, or a permanent resident (green
card holder)? |
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| 17) If not a permanent resident or US citizen, specify type
of non-immigrant status: |
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If other please
specify:
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| 18) If not a permanent resident or US citizen, specify
length of residency in the US: |
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| 19) What is the length of your typical longest contiguous
stay at Fermilab per year ? |
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