Section 13, Part B - Other Type of Insurance - Detailed Questions

Section 13, Part B collects detailed information on non-health insurance policies other than homeowner's insurance, life insurance, tenant's insurance, or vehicle insurance reported in Part A.

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What is the name of the insurance company for "your (1st, 2nd, 3rd)" other type of insurance policy listed? [enter text] ____________________
* Enter name of insurance company, not the insurance agent.

What type of policy is this?

  1. Policy for someone INSIDE the CU
  2. Policy you no longer have
  3. Policy for someone NOT IN YOUR CU

Briefly describe the other type of non-health insurance policy? [enter text] ______________

Briefly describe the other type of non-health insurance policy that you used to have? [enter text] ______________

Briefly describe the other type of non-health policy that you pay for someone outside your CU? [enter text] ______________

Are the policy premiums paid -

  1. Entirely by you or your CU?
  2. Partially by you or your CU and partially by someone outside your CU?
  3. Entirely by an employer or union?
  4. Entirely by another group or persons outside your CU?

Are any premiums paid through payroll deductions?

  1. Yes
  2. No

How often are premiums on this policy paid?

  1. Weekly
  2. Biweekly
  3. Monthly - directly
  4. Monthly - in mortgage payment
  5. Quarterly
  6. Semiannually
  7. Annually
  8. Paid-up policy
  9. Other - Specify

* Specify: [enter text] ___________

Since the first of the reference month, what was your or your CU total expense for this insurance policy? [enter value] ______________

* Enter the actual amount the CU paid. Do not include any expenses paid for the CU by others

How much was paid this month? [enter value] ______________

End of Section 13B Other Type of Insurance

Go back to Section 13 Part B - Insurance Other Than Health - Detailed Questions »

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Last Modified Date: October 11, 2005