Health Insurance - Form 09-2022 - Get My Health Insured

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Step 1 of 19

5%

TCPA Consent*
- Yes
- No
Using DCPA Disclosure method*
- Yes
- No

Requested Coverage Type*
Currently Insured*

Address*
City State ZIP Code
Your Date Of Birth*
Gender*
- Male
- Female

Height in Inches*
Please enter a number greater than or equal to 1.
Weight in pounds*
Please enter a number greater than or equal to 1.
Body Mass Index (BMI)*
Please enter a number greater than or equal to 1.

Marital Status*
Employment status*
Residence Type*

Number of people in household*
Monthly Income of household*
Is a Student*
- Yes
- No

Tobacco user*
- Yes
- No
Abstain from alcohol use*
- Yes
- No
Currently Hospitalized?*
- Yes
- No

Has pre-existing condition*
- Yes
- No
Ongoing treatment*
- Yes
- No
Has prescription medication*
- Yes
- No

Expectant Parent*
- Yes
- No
Number of children*
Previously denied coverage*
- Yes
- No

Name*
First Last
Your Home Phone*
Your Work Phone*
By entering my mobile phone number, I agree to receive autodialed marketing text messages, telephone calls, SMS alerts, and prerecorded voice messaging from an autodialer from AxAdvance.com and other third party marketers at the number I provided. I understand my consent is not required to purchase goods or services, message and data rates may apply, and I may receive recurring monthly messages. Terms and Conditions

Home Address*
Street Address
Email*

Has Arthritis*
- Yes
- No
Has AIDs/HIV*
- Yes
- No
Alcohol or Drug Abuse*
- Yes
- No
Alzheimer's Disease*
- Yes
- No

Asthma*
- Yes
- No
Has Cancer*
- Yes
- No
High Cholesterol*
- Yes
- No
Depression*
- Yes
- No

Has Diabetes*
- Yes
- No
Has heart disease*
- Yes
- No
Has Hepatitis*
- Yes
- No

Kidney Disease*
- Yes
- No
Liver Disease*
- Yes
- No
High Blood Pressure*
- Yes
- No

Mental Illness*
- Yes
- No
Pulmonary Disease*
- Yes
- No
Stroke*
- Yes
- No
Ulcer(s)*
- Yes
- No

Vascular Disease*
- Yes
- No
Heart Disease in family history*
- Yes
- No
Cancer in family history*
- Yes
- No
Received a DUI/DWI*
- Yes
- No

Months living at current residence*
Education*
- Less than High School
- Some or No High School
- High School Diploma
- Some College
- Associate Degree
- Bachelors Degree
- Masters Degree
- Doctorate Degree
- Other

Best Time to Contact*
- Anytime
- Morning
- Afternoon
- Evening
Current Insurance Expiration Date (Required if currently insured)*
MM slash DD slash YYYY
Insured Since Date (Required if currently insured)*
MM slash DD slash YYYY

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