Full Name
*
Date of birth
*
Phone
*
Email
*
City
*
State
*
Postal code
*
Occupation?
Employment status? (Full-Time, Part-Time, Self-Employed, etc.)
Annual Income? (to determine Marketplace subsidy eligibility)
Overall health/Physical condition?
Excellent
Good
Average
Poor
Any pre-existing medical conditions? (Yes/No)
Yes
No
If yes, what's the pre-existing condition?
Cancer
Stroke
Liver Disease
Diabetes
Other Major Condition
Current Medications?
Tobacco use? (Yes/No)
Yes
No
Type of Coverage Desired? (Comprehensive, Basic)
Fully Insured Health Plan
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)n
Point of Service Plan (POS)
Exclusive Provider Organization (EPO)
High Deductible Health Plan (HDHP)
Self-Insured or Self-Funded Plan
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Preferred deductible amount?
Preferred out-of-pocket maximum?
Number of dependents?
Please provide the age and general health status of dependents
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