Request edit access
Does your workplace offer a partner health insurance benefit?
We'd like to know whether your workplace offers a health insurance benefit that covers your same-gender domestic partner.  Tell us about it.  We will not share your name and identifying information with the public.  For Tennessee residents or those who work in Tennessee only, please!
Sign in to Google to save your progress. Learn more
What is your name? *
In what city, state do you live? *
What is the name of the company or organization for which you work?
Are you and your partner/spouse covered by your employer's insurance? *
If you and your partner/spouse use your employer's insurance benefit, how has it helped your family or made life better for you?  Are there situations in which your spouse/partner would have gone without health care if it were not for your employer's commitment to equal benefits?  Would you look for another job if your employer did not have a partner health insurance benefit?  Tell us why it's important to you. *
What is your email address?  We won't share it.  We may want to contact you, though.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report