Form MA-1074 United States Merchant Marine Academy Private Insurance

USMMA Private Insurance Questionnaire

OMB No. 21330543

Expiration Date: 09/30/2014

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2133-0543. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Maritime Administration, MAR-390, 1200 New Jersey Avenue, SE, Washington, DC 20590.

As a USMMA midshipman, your medical care is currently provided through several different vehicles, including a Supplemental Health Care Insurance policy (underwritten by the United States Fire Insurance Company, policy #UEL2672S), which you pay for via midshipman fees. The purpose of this short questionnaire is to find out whether you are covered by any additional private health insurance plan, regardless of whether that health insurance coverage is paid for by you, or by a parent, guardian, spouse, or other source. This feedback will help the Academy best determine the type of health insurance needed by most midshipmen as it transitions to a new program to provide more comprehensive coverage.

1. Are you now covered by a health insurance plan other than the Academy’s Supplemental Policy?

Yes, I am (SKIP TO QUESTION 3)

No, I am not

2. If you ARE NOT covered by another health insurance plan, are you eligible to be included on your parents’ family plan (pick one)?

Yes, I am eligible to be included on my parent’s family plan

No, I am NOT eligible to be included on my parent’s family plan

Don’t know whether I am eligible or not

(END OF QUESTIONS FOR THOSE ANSWERING “NO” TO QUESTION 1)

3. Which best describes that insurance plan (pick one)

My parents pay for my coverage under their “family plan”

I am covered under my parents’ “family plan” but I pay for it

I pay for my own plan

I am covered by a plan provided by a third party (a previous employer, a state, the Military/ TRICARE, etc.

I don’t know

Other (please specify)

4. If you have health insurance, please indicate its coverage (pick one):

All 50 states AND internationally

ONLY the United States (all 50 states)

ONLY my home state (specify) and NY State

ONLY my home state (specify)

Not Sure

5. If you have Health Insurance, please indicate what type of coverage you have (check all that apply)

Hospitalization & Major Medical

Dental

Prescription Medicines

Physician Office Care

Not sure

Other (please specify)

(END OF QUESTIONS FOR THOSE ANSWERING “YES” TO QUESTION 1)

Form MA-1074, May 2012