QUOTE

Name:  
Age:  
Birthday:  
Sex: Male Female
Address:  
City, State Zip:  
County:  
Tobacco use last 6 months? Yes No
Relationship: Single Married
Kids under age 26 Yes No
Daytime Telephone Number:  
Cell Telephone Number:  
E-mail:  
Fax Number:  
Date Plan Needed:
Family Information
ONLY LIST YOUR SPOUSE OR CHILDREN UNDER AGE 26 (OLDEST TO YOUNGEST) IF YOU WANT TO INSURE THEM ON THIS PLAN

DEPENDENT NAME ___ RELATIONSHIP ___ SEX _ AGE__ BIRTHDATE ___ TOBACCO USE LAST 6 MONTHS


If you believe you may qualify for a premium subsidy from the government due to a lower income listed below please provide the following information.


Family of: (1) $45,960 (2) $62,040 (3) $78,120 (4) $94,200 (5) $110,280 (6) $126,360
FAMILY MODIFIED ADJUSTED GROSS INCOME CURRENT YEAR PROJECTION:  
IS EMPLOYER HEALTH COVERAGE AVAILBLE WITH YOUR JOB?  
NUMBER OF FAMILY MEMBERS TO BE INSURED:  
NUMBER OF ADULTS 21 OR OLDER ENROLLING INTO THE MARKETPLACE:  
NUMBER OF CHILDREN 25 AND YOUNGER ENROLLING INTO THE MARKETPLACE:  
Doctors Wanted
Type of Doctor
Location of Doctor
 




     


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