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*Our plans work best with people who are relatively healthy

Employment Status *

Employed

Self-employed

Small Business Owner (2-25 employees)

Unemployed

Do you smoke or use any tobacco/nicotine products? (ex. cigarettes, e-cigarettes, vapes, cigars, smokeless tobacco, etc.) *

Yes

No

Do any of these conditions apply to you? (select all that apply) *

Internal cancer in the last five years

Heart attack or stroke in the last ten years

Type 1 Diabetes (insulin)

Drug or alcohol abuse in the last 4 years

Hospitalized in the last 12 months

Stent Placement

Surgeries in the last five years

None

Estimated Annual Household Income *

Annual Household Income

$0 - $15,000
$15,001 - $25,000
$25,001 - $45,000
$45,001 - $70,000
$70,001 - $100,000
$100,001 - $125,000
$125,001 - $150,000
$150,001+
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State *

County/Parish *

Postal code *

First Name *

Last Name *

Email *

Phone *

Date of birth *

What is your height? *

What is your weight? *

What is the best time to reach you? *

Mornings 8am - 12 noon

Afternoons 12 noon - 3pm

Evenings 3pm - 6pm

Which contact method do you prefer? *

Text

Call

Email

Need to add a spouse? *

Yes

No

Spouse Full Name *

Spouse Date of Birth *

Sex of Spouse *

Male

Female

Spouse Smoker/Tobacco/Nicotine *

Yes

No

Add Dependent 1? *

Yes

No

Full Name of Dependent 1 *

Dependent 1 Date of Birth *

Dependent 1 Sex *

Male

Female

Add Dependent 2? *

Yes

No

Full Name of Dependent 2 *

Dependent 2 Date of Birth *

Dependent 2 Sex *

Male

Female

Add Dependent 3? *

Yes

No

Full Name of Dependent 3 *

Dependent 3 Date of Birth *

Dependent 3 Sex *

Male

Female

Add Dependent 4? *

Yes

No

Full Name of Dependent 4 *

Dependent 4 Date of Birth *

Dependent 4 Sex *

Male

Female

Add Dependent 5? *

Yes

No

Full Name of Dependent 5 *

Dependent 5 Date of Birth *

Dependent 5 Sex *

Male

Female

Additional Information

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