Obamacare Enrollment - Only Four Short Steps

STEP 1 : Tells Us About Yourself

• Priority Code (if you have one)
  
• * First Name
  
• Middle Name
  
• * Last Name and Suffix (if applicable)
  
• Resident Street Address
  
• City
  
• State
  -- Select -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Zip Code
  
• * Phone Number
  
• Mobile Number
  
• * E-mail Address
   
• Do you want to get information about this application by email?
  YesNo
• Date of Birth (mm/dd/yyyy)
  
• Preferred Language
  
• Gender
  FemaleMale
• Are you US Citizien or US National?
  YesNo
• Social Security Number (no dashes)
  
• Do you somke?
  YesNo
• Are you pregnant?
  YesNo
• Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
  YesNo