Do you or have you used tobacco products? *
Is Employer Health Insurance Offered?
Hold down the Ctrl Key to make multiple selections.
Do you plan to file taxes next year? *
How do you plan to file taxes? *
Dependents that need insurance (Claimed on taxes)
Additional Dependents COVERED
If you have additional covered Dependents, please provide the information, as listed above, for each.
Dependents that will NOT be covered by insurance (claimed on taxes).
Additional Dependent NOT Covered
If you have additional dependent in this category, please provide the above listed information for each in the space below.