Medical Enrollment Form Open enrollment. Name* First Last Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleDo You Use Tobacco? Yes No Spouse Name First Last Date of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleDo You Use Tobacco? Yes No Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Best time to contact you?Email* How many children under 21?How many children over 21-26?ChildrenNameDate of BirthSex Would you like to know if you qualify for the On-the-Market-Government tax subsidy?Your Yearly IncomeYour Spouse's Yearly IncomeCAPTCHA