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Client Name *
Date of Birth (mm/dd/yyyy) *
Gender * F   M
Tobacco User * Y   N
   
Spouse Name
Date of Birth (mm/dd/yyyy)
Gender F   M
Tobacco User Y   N
   
City *
Zip *
County *
Phone *
Cell *
Email *
   
Dependent(s)
Date of Birth (mm/dd/yyyy) F   M
Date of Birth (mm/dd/yyyy) F   M
Date of Birth (mm/dd/yyyy) F   M
Date of Birth (mm/dd/yyyy) F   M
   
Do you qualify for a subsidy?
If you qualify for a subsidy or you are not sure, please provide the following
Marital Status Single   Married
If married, do you file taxes jointly? Y   N
Do you have employer coverage available? Y   N
Annual household income
Household size(claimed on tax return)
Other Comments

If you desire personal assistance, please call 770-579-1214 or 800-782-8254.

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