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Affordable Care Act Plans
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Where are you located?
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Step
1
of 5
Where are you located?
Zip_Code
*
Next
Why are you looking for coverage?
reason_for_shopping
Choose One
Recently lost coverage
Currently insured, interested in other options
Uninsured
Next
Let's see if you qualify for financial help!
Members_To_Be_Insured
How many people will be covered?
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2
3
4
5
6
7
8
Household_Members
*
How many people live in your household?
1
2
3
4
5
6
7
8
household_income
Approximate Household Income
$0-$10,000
$10,001-$15,000
$15,001-$20,000
$20,001-$25,000
$25,001-$30,000
$30,001-$35,000
$35,001-$40,000
$40,001-$45,000
$45,001-$50,000
$50,001-$55,000
$55,001-$60,000
$60,001-$65,000
$65,001-$70,000
$70,001-$75,000
$75,001-$80,000
$80,001-$85,000
$85,001-$90,000
$90,001-$95,000
$95,001-$100,000
$100,000 and above
Next
Who would you like to be the primary member on the insurance card?
name
*
First
Last
Next
How can we reach you?
Phone
*
Email
*
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