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ABOUT 4-10

INDIVIDUAL PLANS

GROUP PLANS

RESOURCES

CONTACT INFORMATION
(Note: It is easiest to "tab" between fields)
* Name	(first)		(last)
* Email @
Address
City			State	California Arizona Oregon Washington	* Zip
* Daytime Phone	xxx-xxx-xxxx
Evening Phone	xxx-xxx-xxxx
Best Time Time to Contact	Select Morning Afternoon Evening
HEALTH INFORMATION
Pre-Existing Health Condition				NO YES
	If Yes Please Specify:		Asthma Heart Condition Cancer High Blood Pressure Diabetes Pregnant
Taking Medications				NO YES
If Yes Please Specify:
FAMILY MEMBERS TO BE INSURED
Gender Date of Birth mm / dd / yy Height Weight Full Time College Student (Dependent children ages 19 through 23 can only be included if they are full time students) Subscriber M F 1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 4Ft 5Ft 6Ft 7Ft Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. Spouse -- M F 1 2 3 4 5 6 7 8 9 10 11 12 -- / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 -- 4Ft 5Ft 6Ft 7Ft Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. Child -- M F 1 2 3 4 5 6 7 8 9 10 11 12 -- / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 -- Ft 1Ft 2Ft 3Ft 4Ft 5Ft 6Ft 7Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. NO YES Child -- M F 1 2 3 4 5 6 7 8 9 10 11 12 -- / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 -- Ft 1Ft 2Ft 3Ft 4Ft 5Ft 6Ft 7Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. NO YES Child -- M F 1 2 3 4 5 6 7 8 9 10 11 12 -- / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 -- Ft 1Ft 2Ft 3Ft 4Ft 5Ft 6Ft 7Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. NO YES Child -- M F 1 2 3 4 5 6 7 8 9 10 11 12 -- / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 -- Ft 1Ft 2Ft 3Ft 4Ft 5Ft 6Ft 7Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. NO YES Child -- M F 1 2 3 4 5 6 7 8 9 10 11 12 -- / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- / 05 04 03 02 01 00 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 82 81 80 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66 65 64 63 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 -- Ft 1Ft 2Ft 3Ft 4Ft 5Ft 6Ft 7Ft In 1in 2in 3in 4in 5in 6in 7in 8in 9in 10in 11in 12in Lbs. NO YES

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