Health legal checkup
Medical Benefits Check-up
Please select all that apply to you
Do you have children (under the age of 27) who do not have medical coverage?
Yes I have children/a child who do not have medical coverage. They are between the ages of 15-26
I do have children/a child who does not have medical coverage. My child/children are below the age of 15.
Should be Empty:
Copyright 2016 JotForm Inc.