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What is your gender?
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What month were you born?
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What day were you born?
01
02
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20
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Birth Year?
19
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What is your height?
(Select feet FIRST then inches)
4 ft.
0 in.
1 in.
2 in.
5 ft.
3 in.
4 in.
5 in.
6 ft.
6 in.
7 in.
8 in.
7 ft.
9 in.
10 in.
11 in.
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What is your current annual income?
None
5k
10k
15k
20k
30k
40k
50k
60k
70k
80k
100k +
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How many people live in your household?
1
2
3
4
5
6
7
8
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What is your weight? (lbs.)
70
75
80
85
90
95
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270+
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Do you use Tobacco?
YES
NO
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Do you have any of these medical conditions?
AIDS / HIV
Liver Disease
Alzheimer's Disease
Pulmonary Disease
Heart Disease
Mental Illness
Cancer
Stroke
Kidney Disease
Diabetes
Drug Abuse
Vascular Disease
Depression
None Apply
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Do you currently have Health Insurance?
YES
NO
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Select Your Carrier
PLEASE SELECT
AARP
Advantra
Aetna
Alameda Alliance for Health
Altius Health Plans
American Community Mutual Insurance Company
American Republic Insurance Company
American Security Life
American Specialty Health
Amerihealth
Anthem Blue Cross and Blue Shield of Colorado
Anthem Blue Cross and Blue Shield of Connecticut
Anthem Blue Cross and Blue Shield of Indiana
Anthem Blue Cross and Blue Shield of Maine
Anthem Blue Cross and Blue Shield of Nevada
Anthem Blue Cross and Blue Shield of Ohio
Anthem Blue Cross and Blue Shield of Virginia
Arcadian Health Plan
Arkansas Blue Cross and Blue Shield
Assurant (previously Fortis)
Asuris NorthWest Health
Atlantis Health Plan
AultCare
Avmed Health Plan
BadgerCare Plus
Bankers Fidelity Life Insurance Co.
Blue Cross and Blue Shield of Minnesota
Blue Cross Blue Shield of Alabama
Blue Cross Blue Shield of Arizona
Blue Cross Blue Shield of Florida
Blue Cross Blue Shield of Georgia
Blue Cross Blue Shield of Hawaii
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield of Kansas
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Missouri
Blue Cross Blue Shield of Nebraska
Blue Cross Blue Shield of New Jersey
Blue Cross Blue Shield of New Mexico
Blue Cross Blue Shield of New York
Blue Cross Blue Shield of North Carolina
Blue Cross Blue Shield of Oregon
Blue Cross Blue Shield of South Carolina
Blue Cross Blue Shield of Tennessee
Blue Cross Blue Shield of Texas
Blue Cross Blue Shield of Vermont
Blue Cross Blue Shield of Wisconsin
Blue Cross of California
Blue Cross of Idaho
Blue Cross of Massachusetts
Blue Cross of North Eastern PA
Blue Shield of California
Blue Shield of Washington
BlueCross BlueShield of Kansas City
BlueGrass Family Health
Capital Blue Cross
CareFirst Blue Cross Blue Shield
Celtic Insurance Company
Centene Corp
CHA Health
Charter Oak Health Plan
Cigna
CIGNA of Arizona
Clarendon National Insurance Company
CNA/Highway to Health
Cole Vision
Community Health Plan
Companion HealthCare
Connecticut General Life Insurance Company
Cover Florida
CoverColorado
CoverTN
CPIC Life
Dean Health Plan
Destiny Health Plan
Empire Blue Cross Blue Shield of NY
Excellus Blue Cross Blue Shield of Rochester
Fairmont Specialty Group
Fallon Health Plan
Family Health Plus
FirstCare
FiServ Health
Fortis Health (now Assurant)
Geisinger Health Plan
GoBlue
Golden Rule
Great West HealthCare
Group Health Cooperative
Group Health Incorporated
Guardian Vista Health of South Florida
Guardian/Health Net
Harvard Pilgrim
Hawaii Pacific Health
Hawk-I
Health Alliance Plan of Michigan
Health First Health Plan
Health Net of Arizona
Health Net of California
Health Net of Oregon
Health Plan of Nevada
HealthFirst of New York
HealthPartners
Healthspring
Healthy Indiana Plan
HIP
Horizon Blue Cross Blue Shield
HTH (International)
Humana
Independence Blue Cross Blue Shield
Insure Oklahoma
Intermountain Health Plan
International Medical Group (International)
International SOS (International)
John Alden (A Fortis Health Co.)
John Deere Health Care
Kaiser Permanente of California
Kaiser Permanente of Colorado
Kaiser Permanente of Georgia
Kaiser Permanente of Ohio
Kaiser Permanente of Oregon
Kaiser Permanente of the Mid- Atlantic States, Inc.
Kanawha Insurance Company
Keystone Blue Cross Blue Shield
KPS Health Plan
LifeWise Health Plan of Oregon
LifeWise of Arizona
Lifewise of Washington
Lovelace health Plan
MAMSI
Medex (International)
Medica
Medical Mutual of Ohio
MEGA Health
Mercy Health Plan
Midwest Security
MinnesotaCare
Molina HealthCare
Monumental Life
Mountain State Blue Cross Blue Shield
MVP Health Plans
National Health Insurance Company
Nationwide Health Plans
Neighborhood Health Plan
New York Life
ODS Alaska
ODS Health Plan of Oregon
Optima Health
Optimum Choice
Other
Oxford Health Plans
PacifiCare of Arizona
PacifiCare of California
PacifiCare of Colorado
PacifiCare of Nevada
PacifiCare of Oklahoma
PacifiCare of Oregon
PacifiCare Vision
PacificSource Health Plan
Preferred One
Premera Blue Cross Blue Shield of Alaska
Premera Blue Cross of Washington
Principal Life Insurance Company
Priority Health
Providence Health Plan
PrudentChoice (health discount plan)
Qualchoice
Regence BC/BS of Oregon
Regence BlueShield
Rocky Mountain Health Plan
SCAN Health Plans
Security Life Insurance Co. of America
SelectHealth
Sierra Health Plans
State Farm Health
SummaCare
Time Insurance
Torchmark
TrustMark Insurance Company
Tufts Health Plan
Tufts Secure Horizons
Ucare
UNICARE Life & Health Company
Unison Health Plan
United American Insurance Company
United Health Care Group
United Wisc. Life Ins./Am. Medical Sec.
Unity Health Plan
Univera
UPMC Health Plan
Vista Health Plan
VIVA Health
Washington Basic Health Plan
WellChoice
Wellmark Blue Cross Blue Shield of Iowa
Wellmark Blue Cross Blue Shield of South Dakota
Wellpath Select
Wellpoint Inc.
World Insurance Company
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Does any of these Life Conditions apply to you?
Married or Divorced
Had Baby
Family Member Died
Moved to new State
Lost My Job
Started New Job
Lost Current Coverage
None Apply
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What is your full name?
First Name
Last Name
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What is your email address?
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What is your phone number?
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What is your address?
Street Address
Moscow
, Lenina st., bld. 12
Zip Code
City
State
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