Health Coverage Qualification Survey
Please answer the following questions to determine your health coverage eligibility.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you currently have health insurance?
Option 1
Option 2
Option 3
Are you employed?
Option 1
Option 2
Option 3
Do you have any pre-existing medical conditions?
Option 1
Option 2
Option 3
Are you a smoker?
Option 1
Option 2
Option 3
Do you have dependents?
Option 1
Option 2
Option 3
Submit
Should be Empty: