Alabama Self Employed Health Insurance Premium Reduction Form What state do you live in?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificWhat is the nature of your Self-Employment? I own a small business I am a realtor I work for a company as a 1099 Independent Contractor I work for a company that doesn't provide health coverage Do you currently have a healthcare policy? (current coverage is not a requirement)Are you currently receiving a government subsidy toward your health policy?Have you had a major medical condition such as cancer, or heart disease in the past 3 years?What is your approximate height?5-0 or under5-15-25-35-45-55-65-75-85-95-105-116-06-16-26-3 or moreWhat Is Your Current Weight? 100 lbs or less 101-125lbs 126-150lbs 151-175lbs 176-200lbs 201-225lbs 226-250lbs 251 lbs or greater What is your date of Birth? MM slash DD slash YYYY Have you used Nicotine products in the last 2 years? (we have great options for smokers.) What email would you like us to send your results too? (We hate spam and will not share your information) Cell Phone Number with Area CodeWho all would you like a quote for?Please provide any other information or questions that you might have. If you have a spouse or children you want a quote for please add their names and date of birth below.Name First Last Zip code Δ
