Utah Health Policy Project

508 East South Temple, Suite 45; Salt Lake City, Utah 84102 www.healthpolicyproject.org

Utah Small Business Story Bank Questionnaire

First Name: _______________________

Last Name:__________________________________

Business Name: _________________________

Web Site: _____________________________

Address: _______________________________________________________________________
City: __________________________

State:_________

Home Phone: (_____) ______-___________

Zip:_____________-_________

Work Phone: (_____) ______-______________

Email: _____________________@_____________________________________
Type of Business: _________________________________________________________________
Is your business locally owned?

Yes

No

Is your business a nonprofit?

Yes

No

How many full-time employees, including yourself, do you have? ________

How many part-time employees? _________
Annual Revenues (approx.):$ __________
Total average wages paid per employee: $ ____________

Does your business currently offer health insurance to your employees?

YES No

IF YES: Total annual employer premium contribution: $ __________

What percent of the premium do you cover? __________
What percent of your workers take up the coverage, not counting those who have coverage through
their spouse or partner __________________?
What is the approximate average age of your workforce? _______
Do you have health insurance for yourself?

YES

No

Do you have health insurance for your family?

YES

No

Please describe this coverage?

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

How much has your premium increased by in the last 5 years? ___________
The last two years? __________ Last year?______________
What has been your experience trying to find affordable coverage for your workers?
__________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do employees at your business have trouble covering their portion of the premium? YES No

IF NO: Would you like to be able to offer coverage to your workers? YES

No

What are the reasons you do not offer insurance (e.g., affordability, lack of demand or interest):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How much of a premium subsidy would you need to be able to offer coverage to your workers? ______
Does the current cost of coverage impact your business profitability or ability to compete competitively
in your business sector?
YES No
If no, are you concerned that it will soon? YES

No

Please elaborate:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does the current cost of coverage impact your ability to attract/retain quality employees? YES
If no, are you concerned that it will soon? YES

No

No

Please elaborate: ___________________________________________________________________

__________________________________________________________________________________
Are you aware of the tax credits now available to small businesses through the Patient Protection and
Affordable Care Act? YES No
Would you like to receive weekly information regarding how the PPACA supports small businesses:
YES
No

Does your company plan on applying for the small business exchange?
Would you be interested in joining our Exchange Learning Network?

The following link provides information on how the PPACA assists small businesses:
http://www.healthpolicyproject.org/Business.html
www.exchange.utah.gov