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Personal Information:
Name
Date Of Birth
Contact Number
Email
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky[D]
Louisiana
Maine
Maryland
Massachusetts[D]
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania[D]
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia[D]
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Insurance Details:
Insurance Type:
Family Health Insurance
Individual
Parents
Senior Citizens
Members:
1
2
3
4
5
Age:
Health Issue?
Yes
No
Spouse?
Yes
No
Dependent?
Yes
No
Household Information:
Household Size:
1
2
3
4
5
6
7
8
Household Income (Yearly):
Less Then $13000
$13,001 to $17,000
$17,001 to $20,000
$20,001 to $25,000
$25,001 to $30,000
$30,001 to $35,000
$35,001 to $40,000
$40,001 to $45,000
$45,001 to $50,000
$50,001 to $55,000
$55,001 to $60,000
$60,001 to $65,000
$65,001 to $70,000
$70,001 to $75,000
$75,001 to $80,000
$80,001 to $85,000
$85,001 to $90,000
$90,001 to $95,000
$95,001 to $99,999
$100,000 or Above
As per ACA(Affordable Care Act) regulations, plan pricing and availability will be determined by your household size & household income as it relates to the FPL(federal poverty level) Chart.
Additional Information:
Do you have a current health insurance policy?
Yes
No
Any pre-existing conditions on your health?
Yes
No
Comments:
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