ACA Quote Form - Davina

Your Name [required] *

First Name

Last Name

Your Telephone Number [required] *

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Your Date of Birth [required] *

Date of Birth is a required element on the Affordable Care Act Marketplace

MM

DD

YYYY

Your Sex [required] *

Sex is a required element on the Affordable Care Act Marketplace

Female

Male

Do You Need Coverage? [required] *

All members of your tax household must be listed, even those who will not be covered/insured by the plan.

Yes

No

Will you file 2025 taxes with a spouse or any dependents? [required] *

Yes

No

Preferred Contact Method/s [required] *

Phone Call

Text

Email

Name of Tax Household Member 2 [required]

First Name

Last Name

Date of Birth of Tax Household Member 2 [required]

Date of Birth is a required element on the Affordable Care Act Marketplace

MM

DD

YYYY

Sex of Tax Household Member 2 [required]

Sex is a required element on the Affordable Care Act Marketplace

Female

Male

Does This Person (THM2) Need Coverage? [required]

All members of your tax household must be listed, even those who will not be covered/insured by the plan.

Yes

No

Name of Tax Household Member 3 [required]

First Name

Last Name

Date of Birth of Tax Household Member 3 [required]

Date of Birth is a required element on the Affordable Care Act Marketplace

MM

DD

YYYY

Sex of Additional Tax Household Member 3 [required]

Sex is a required element on the Affordable Care Act Marketplace

Female

Male

Does This Person (THM3) Need Coverage? [required]

All members of your tax household must be listed, even those who will not be covered/insured by the plan.

Yes

No

Name of Tax Household Member 4 [required]

First Name

Last Name

Date of Birth of Tax Household Member 4 [required]

Date of Birth is a required element on the Affordable Care Act Marketplace

MM

DD

YYYY

Sex of Tax Household Member 4 [required]

Sex is a required element on the Affordable Care Act Marketplace

Female

Male

Does This Person (THM4) Need Coverage? [required]

All members of your tax household must be listed, even those who will not be covered/insured by the plan.

Yes

No

Name of Tax Household Member 5 [required]

First Name

Last Name

Date of Birth of Tax Household Member 5 [required]

Date of Birth is a required element on the Affordable Care Act Marketplace

MM

DD

YYYY

Sex of Tax Household Member 5 [required]

Sex is a required element on the Affordable Care Act Marketplace

Female

Male

Does This Person (THM5) Need Coverage? [required]

All members of your tax household must be listed, even those who will not be covered/insured by the plan.

Yes

No

Name of Tax Household Member 6 [required]

First Name

Last Name

Date of Birth of Tax Household Member 6 [required]

Date of Birth is a required element on the Affordable Care Act Marketplace

MM

DD

YYYY

Sex of Tax Household Member 6 [required]

Sex is a required element on the Affordable Care Act Marketplace

Female

Male

Does This Person (THM6) Need Coverage? [required]

All members of your tax household must be listed, even those who will not be covered/insured by the plan.

Yes

No