Number of Children 1 2 3 4 5 6 7 8 9 10+ Do You Currently Have Health Insurance? Yes No Do You Currently have Dental Insurance? Yes No Are you a Smoker? Yes No Reason for Changing Insurance Losing Insurance Seeking a Better Rate Seeking Better Care Don't Currently Have Insurance Get a quote

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Reason for Considering Change Rates Poor Service Poor Benefits Other Plan to Include Vision? Yes No Plan to Include Dental? Yes No Get a quote

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Your age... 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

Have you used tobacco or nicotine products in the last 12 months?

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