(* Required information)


  *First name:  

  *Last name:  

  *Address:      

  *City:          

  *State:        AA AE AK AL AP AR AZ CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VI VT VA WA WV WI WY

  *ZIP code:

  *Date of birth: -- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000


  *Are you a (check one):
     Federal employee or spouse
     Postal employee or spouse
     Federal or postal annuitant or spouse
  (Only members of these groups are eligible.)


  *If federal employee or spouse, please choose the agency or department you or your spouse works for:

   Please select: Environmental Protection Agency Federal Deposit Insurance Corporation General Services Administration Internal Revenue Service National Aeronautics and Space Administration National Archives & Records Administration Nuclear Regulatory Commission Office of Personnel Management Small Business Administration Smithsonian Institution Social Security Administration Transportation Security Administration United States Postal Service Department of Agricultural Department of Commerce Department of Defense Department of Education Department of Energy Department of Health and Human Services Department of Homeland Security Department of Housing and Urban Development Department of the Interior Department of Justice Department of Labor Department of State Department of Transportation Department of the Treasury Department of Veterans Affairs All Other Agencies  


  *Current health plan (check one):

   Please select: APWU Health Plan - Consumer Driven Option APWU Health Plan - High Option Association Benefit Plan Blue Cross and Blue Shield - Basic Option Blue Cross and Blue Shield - Standard Option Foreign Service Benefit Plan GEHA Health Savings Advantage HDHP GEHA Benefit Plan - High Option GEHA Benefit Plan - Standard Option Mail Handlers Benefit Plan - Consumer Option HDHP Mail Handlers Benefit Plan - Standard Option Mail Handlers Benefit Plan - Value Plan NALC (National Association of Letter Carriers) No health insurance Health Insurance through Spouse (no FEHBP coverage)/Other HMO (Any Other) CDHP (Any Other) HDHP ( Any Other) Panama Canal Area Benefit Plan Rural Carrier Benefit Plan SAMBA Don't know Other  

  *Current coverage (check one):  
Self and family
Self only  

  Phone number:   - -

  E-mail address: 

  *How did you hear about this offer?
Personal mailing
Newspaper
Magazine
Internet
Health Fair
Email
Other

  If you learned about this offer from a Personal mailing, please provide the ID number printed on the ad or mailing.   

  Would you be willing to participate in future surveys, focus groups or website usability studies?
Yes
No

  I give my permission for MHBP to send me information using the email I have provided
Yes
No

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