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Are you inquiring about yourself or a child?
Self
Children
Both
Do you currently have insurance?
Yes
No
Do you have children (dependents) without insurance?
Yes
No
Have you had insurance within the last year?
Yes
No
You may be eligible for free or low cost state benefits - what is your yearly household income?
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999
$30,000 - 39,999
$40,000 - 49,999
$50,000 - 59,999
< $100,000
Monthly Income
What is your primary mode of transportation?
What is your primary language?
Do you have internet access at home
Yes
No
Can a specialist contact you to help you get benefits?
Yes
No
Phone
Email
