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Insurance quote questionnaire
Obamacare Quote questionnaire
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* Indicates required question
Full Name / Nombre completo
*
Your answer
Email address / Correo Electrónico
*
Your answer
Phone number / Teléfono
*
Your answer
Zip code / Código Postal
*
Your answer
Age of principal Applicant /
Edad del solicitante principal
*
Your answer
Age of Spouse /
Edad del cónyuge
*
Your answer
Age and sex of Dependents /
Edad y sexo de los dependientes
*
Your answer
How do you file your taxes? Cómo presenta sus impuestos?
*
Single
Head of Household
Married filling jointly
Married filling seperate
How many household members need health insurance?/ ¿Cuántos miembros del hogar necesitan seguro médico?
*
Father/ Padre
Mother / Madre
Child/ Niño 1
Child/ Niño 2
Child/ Niño 3
Required
Do your children need Health Insurance? / ¿Sus hijos necesitan seguro médico?
*
Yes
No
Total individuals claimed in this household's tax filing
/ Total de personas declaradas en la declaración de impuestos de este hogar
*
Your answer
Total Yearly Household Income /
Ingreso total anual del hogar
*
Your answer
Signature
*
Your answer
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