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Gender:	YesNo
DOB:
Address: *
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Smoker:	YesNo
Married:	YesNo
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Native American?:	YesNo
Spouse
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SSN:
DOB:
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Employer(s):
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Smoker:	YesNo
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Native American?:	YesNo
Dependents
Name DOB SSN Gender Income Male Female Male Female Male Female Male Female Male Female
Dr.: Dr.: Dr.: Dr.:
Medical Plan:
Medical Premium: $:
Dental Plan: Dental Premium: $ Toal: $
FPL:	%
APTC $:
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