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Name
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Email address
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What type of healthcare coverage are you interested in?
Please select at least one option.
Private health insurance
ACA health plans
Short-term health insurance
Medicare
Medicaid
What is your age group?
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Under 18
18-34
35-49
50-64
65 and above
Are you self-employed or a business owner?
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Yes
No
What is your primary concern regarding healthcare coverage?
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Cost
Coverage options
Network of providers
Family coverage
Pre-existing conditions
Do you currently have health insurance?
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Yes
No
If yes, what type of plan do you currently have?
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Employer-sponsored plan
Individual plan
Government plan (Medicare/Medicaid)
What is your estimated annual income?
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Under $25,000
$25,000 - $50,000
$50,000 - $75,000
$75,000 - $100,000
Over $100,000
Do you have any specific medical needs or conditions?
Additional questions or comments
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