IRISH DANCE TEACHERS ASSOCIATION OF

NORTH AMERICA              

  Associated with An Coimisiun le Rince Gaelacha

 
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IDTANA Health Insurance Survey

Dear Members of the IDTANA:

The following survey is being conducted of the IDTANA members in an effort to secure a National HealthCare Plan that would be offered and available to all current, future and retired members of the IDTANA.   This is a crucial time for organizations such as ours to sponsor health insurance programs for their self-employed members.   The Equity for Our Nation's Self-Employed Act, introduced recently in the House of Representatives would eliminate the current inequity in the tax code that inhibits the self-employed from receiving a full deduction for health insurance costs.  In addition,  this legislation would assist in making health care more affordable for millions of self-employed Americans.

Unfortunately at this time we are only soliciting information from our US members, and not our members in Canada.  

Please complete the following.   Please note that the information provided will be used solely to formulate demographics to submit to health care providers to secure a group rated health insurance program.  Any Protected Health Information (PHI) as regulated under HIPAA will be secured and used only for this purpose.  The survey needs to be completed by November 12, 2007.  There is no obligation if you complete the survey.   If you have any questions, please feel free to contact me preferably be email, or by phone. 

Thank you, 

Michael Mullane ADCRG

 

Please provide the following contact information:

 
         Personal Information   Type of Coverage
Name                  Choose one of the following options:
An Coimisiun Reg #    
Region   Complete the following for each potential covered dependent including self:
State    
Zip/Postal Code   IDTANA Mbr:            
E-mail   Sex    Male Female Date of Birth        
     
      Name                          

Do you currently have health insurance?                      Yes No

   Sex    Male Female Date of Birth       
Carrier:   
Other:   Name                          

Is it a COBRA policy that expires within 24 months?  Yes No

   Sex    Male Female Date of Birth       
Expiration Date:  

 

   Name                         
      Sex    Male Female Date of Birth       
 

Comments or Questions:   

 

 

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Revised: October 16, 2007