Health

Name *

Address *

Phone *

Email *

Referred by

Date *

Covering spouse? *YesNo

Covering children? *YesNo

(If covering spouse and/or children, please provide details below)

Applicant

Name

Date of birth

Gender: MaleFemale

Tobacco use? YesNo

Date last used tobacco?

Spouse

Name

Date of birth

Gender: MaleFemale

Tobacco use?YesNo

Date last used tobacco?

Child 1

Name

Date of birth

Gender: MaleFemale

Tobacco use? YesNo

Date last used tobacco?

Child 2

Name

Date of birth

Gender: MaleFemale

Tobacco use? YesNo

Date last used tobacco?

Child 3

Name

Date of birth

Gender: MaleFemale

Tobacco use? YesNo

Date last used tobacco?

Child 4

Name

Date of birth

Gender: MaleFemale

Tobacco use? YesNo

Date last used tobacco?

If you think you may qualify for a subsidy on exchange,
provide estimated household income for 2014 (includes income from all individuals in household working in 2014 including children)

Number of people in household

Effective date for coverage

Current coverage (carrier, deductible, copay, coinsurance,
COVERAGE do you have HSA?, current monthly premium)

* indicates required fields