Your name *
Your name
Do you currently have health insurance? *
If "yes," do you have a subsidized health insurance plan through Covered California? *
(government subsidized)
If you do not have insurance, write "n/a"
What is your monthly premium? If you do not have coverage, leave blank.
If you don't know, just take your closest guess. If you don't have health insurance, leave blank.
If you do not have insurance, leave blank.
Do you have dental insurance? *
If yes, please write their full name and city of business below. If no, leave blank.
Are you interested in a Krimsey's Health Insurance Plan? *