Fact Finder

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Do you use tobacco products?*:

Spouse

Gender*:
Does your spouse use tobacco products?*:

Dependents

Need Coverage? Name Gender DOB Income Tobacco

General Questions

Are all proposed insured U.S. Citizens?

Have you lived in the U.S. since 1996?

A veteran or an active-duty member of the U.S. Military?

Indian or Alaskan native?

If yes, please provide the name and location:

Are any of the individuals applying for coverage currently pregnant?

If yes, how many babies will you be expecting?:

Changes or loss in current coverage?