Name: Phone: Your email: Birth Year: Number of people in house hold: Annual House Hold Income: 0 – 15,000K15,001 – 32,000K32,001 – 40,000K40,001 – 50,000K50,001 – 75,000K75,001 – 85,000K85,001 – 100,000K+ Gender: MaleFemale Tobacco use in the past 6 months: YesNo Employment Status: EmployedSelf-EmployedRetiredStudentStay at Home ParentNot Currently Working When do you need coverage: As soon as possibleIn the next 30 daysMore than 30 daysNot Sure