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		Date of Birth	Tobacco usage in last 12 months?	Full Time College Student?
	Gender	Month/dd/yyyy
Applicant	choose male female	January February March April May June July August Sept October November December / /	yes	yes
Spouse	choose male female	January February March April May June July August Sept October November December / /	yes	yes
Child1	choose male female	January February March April May June July August Sept October November December / /	yes	yes
Child2	choose male female	January February March April May June July August Sept October November December / /	yes	yes
Child3	choose male female	January February March April May June July August Sept October November December / /	yes	yes
Your Zip Code		Comments:		I want my coverage to begin on

 

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