nationwidehealthalliance.com
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34.68.234.4
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URL:
https://nationwidehealthalliance.com/
Submission: On July 15 via automatic, source certstream-suspicious — Scanned from DE
Submission: On July 15 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
Name: builder-form —
<form id="_builder-form"
style="background-color:#FFFFFF;color:#undefined;border:1px none #CDE0EC;border-radius:8px;max-width:550px;width:100%;margin-top:;border-color:#CDE0EC;padding-top:20px;padding-bottom:0px;padding-left:40px;padding-right:40px;box-shadow:0px 15px 33px 4px #00000026;"
name="builder-form" class="ghl-survey-form" data-v-fd05e6d5=""><!---->
<div class="ghl-question-set" style="margin-top:2px;" data-v-fd05e6d5=""><!--[-->
<div class="ghl-page-current form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-first_name" class="form-builder--item-input form-builder--item"><!----><label>First Name <span>*</span></label><input type="text" placeholder="First Name" name="first_name" class="form-control" id="first_name"
data-q="first_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-last_name" class="form-builder--item-input form-builder--item"><!----><label>Last Name <span>*</span></label><input type="text" placeholder="Last Name" name="last_name" class="form-control" id="last_name"
data-q="last_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Email <span>*</span></label>
<div>
<div class="flex email-input"><input placeholder="Email" name="email" type="email" class="form-control" data-q="email" data-required="true"><!----></div><!----><!---->
</div><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-phone" class="form-builder--item-input form-builder--item"><!----><label>Phone <span>*</span></label>
<div>
<div class="flex phone-input" style=""><input type="tel" name="phone" placeholder="Phone" autocomplete="off" class="form-control" id="phone" data-q="phone" data-required="true"><!----></div><!----><!---->
</div><!----><!----><!---->
</div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-1Yrd8nvEZkkQS1piNLfW" class="form-builder--item-input form-builder--item"><!----><label>Primary Date of Birth MM/DD/YYYY <span>*</span></label><input type="text" placeholder="MM/DD/YYYY" name="1Yrd8nvEZkkQS1piNLfW"
class="form-control" id="1Yrd8nvEZkkQS1piNLfW" data-q="primary_date_of_birth_mm-dd-yyyy" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">What is your gender? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Male_xKYaCqTPv7zieGZ4tTWS_0_d34x7k1w1jh" value="Male" type="radio" data-q="what_is_your_gender?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Male_xKYaCqTPv7zieGZ4tTWS_0_d34x7k1w1jh">Male</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Female_xKYaCqTPv7zieGZ4tTWS_1_d34x7k1w1jh" value="Female" type="radio" data-q="what_is_your_gender?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Female_xKYaCqTPv7zieGZ4tTWS_1_d34x7k1w1jh">Female</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1100FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Where should we send your insurance cards?</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:15px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center">PO Box is not accepted. Physical address only. </p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-address" class="form-builder--item-input form-builder--item"><!----><label>Address <span>*</span></label><input type="text" placeholder="Address" name="address" class="form-control" id="address" data-q="address"
data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-city" class="form-builder--item-input form-builder--item"><!----><label>City <span>*</span></label><input type="text" placeholder="City" name="city" class="form-control" id="city" data-q="city"
data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-state" class="form-builder--item-input form-builder--item"><!----><label>State <span>*</span></label><input type="text" placeholder="State" name="state" class="form-control" id="state" data-q="state"
data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-postal_code" class="form-builder--item-input form-builder--item"><!----><label>Postal code <span>*</span></label><input type="text" placeholder="Postal Code" name="postal_code" class="form-control" id="postal_code"
data-q="postal_code" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1E00FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Moving right along, we just need a quick signature to continue:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:14px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>I hereby authorize Logan Holle to act as my authorized representative for health insurance matters, including but not limited to, enrolling myself and, if applicable, my household, in a Qualified Health Plan through the Federally
Facilitated Marketplace. This consent encompasses the following authorizations for Logan Holle:</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:14px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><strong>1. To access and manage any existing Marketplace applications;</strong></p>
<p><strong>2. To facilitate eligibility assessments and enrollment in Marketplace Qualified Health Plans or other related government programs (e.g., Medicaid, CHIP, advance tax credits);</strong></p>
<p><strong>3. To provide necessary ongoing support and enrollment assistance;</strong></p>
<p><strong>4. To handle inquiries from the Marketplace related to my application;</strong></p>
<p><strong>5. To switch my plan to a superior option if available or otherwise act as my agent of record, subject to my right to alter this authorization;</strong></p>
<p><strong>6. To acknowledge my income is below 100% of the federal poverty level and I agree to actively seek employment that pays at least the minimum wage.</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:14px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>I affirm that Logan Holle is permitted to use my personally identifiable information (PII) solely for the purposes listed above, pledging to maintain the confidentiality and security of such information. I declare that all
information provided for my eligibility and enrollment will be accurate to the best of my knowledge. I acknowledge that sharing additional personal or health information beyond what is required for application purposes is not
obligatory. This consent is effective until revoked, which I may do at any time via email, text, or phone call to Logan Holle at the contact details provided below.</p>
<p></p>
<p><strong>Primary Writing Agent: Logan Holle</strong></p>
<p><strong>National Producer Number: 18496827</strong></p>
<p><strong>Phone: +602-699-4545 </strong></p>
<p><strong>Email: </strong><a target="_blank" rel="noopener noreferrer nofollow" href="mailto:loganholleaca@gmail.com"><strong>loganholleaca@gmail.com</strong></a></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item" data-v-fd05e6d5="">
<div class="terms-and-conditions"><input id="terms_and_conditions_d34x7k1w1jh" value="terms_and_conditions" name="terms_and_conditions" type="checkbox" data-q="terms_and_conditions" data-required="true"><span
style="font-family:Inter;margin-left:10px;" for="terms_and_conditions_d34x7k1w1jh"><span style="color: #000000;">
<p>I agree to <a style="color: #188bf6; text-decoration: none;" target="_blank" rel="noopener noreferrer nofollow" href="https://www.example.com">terms & conditions</a> provided by the Nationwide Health Alliance. By providing
my phone number, I agree to receive text messages from the business.</p>
</span></span></div><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item" data-v-fd05e6d5=""><label class="item-description"></label><label>Sign Below <span>*</span></label>
<section class="signature-container">
<div style="width: 100%;"><canvas class="signature-button" style="min-height: 150px; touch-action: none; user-select: none;"></canvas></div><a aria-label="Clear" class="clear-button">Clear</a>
</section><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#2600FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Next, we need to check your program eligibility:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-6yB3CV2wiTFOVP6XXw3h" class="form-builder--item-input form-builder--item"><label class="item-description"></label><label>Primary Applicant's Social Security Number <span>*</span></label><input type="text"
placeholder="xxx-xx-xxx" name="6yB3CV2wiTFOVP6XXw3h" class="form-control" id="6yB3CV2wiTFOVP6XXw3h" data-q="social_security_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:15px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><em>This is required by Healthcare.gov to verify your identity.</em></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--img-wrap" style="justify-content:center;" data-v-fd05e6d5="">
<div class="form-builder--item form-builder--image"><img class="hl-un-optimized mw-100"
src="https://images.leadconnectorhq.com/image/f_webp/q_85/r_1000/u_https://storage.googleapis.com/highlevel-backend.appspot.com/location/ZEgBOYA0NimImViHQngi/form/kyYG207kEsnPSNPJXQxn/cd204bd6-bc9c-4cd0-ac42-e63294ef45b3.png"
style="width:100px;height:100%;" loading="lazy"></div>
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#0800FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Tell us about your current coverage:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#FF0000FF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:15px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><strong>IMPORTANT:</strong> If you are currently enrolled in a Medicare or Medicaid plan you will not qualify.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#FF0000FF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:15px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>However, if you recently lost coverage please continue with the application.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Are you currently enrolled in Medicare OR Medicaid? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_iLve1TqfmhBdUgdFiV8j_0_d34x7k1w1jh" value="Yes" type="radio"
data-q="do_you_or_anyone_in_your_household_applying_for_coverage_have_medicare,_medicaid_or_va_coverage?" data-required="true"><label style="margin-left:10px;margin-bottom:0;"
for="Yes_iLve1TqfmhBdUgdFiV8j_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_iLve1TqfmhBdUgdFiV8j_1_d34x7k1w1jh" value="No" type="radio"
data-q="do_you_or_anyone_in_your_household_applying_for_coverage_have_medicare,_medicaid_or_va_coverage?" data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="No_iLve1TqfmhBdUgdFiV8j_1_d34x7k1w1jh">No</label>
</div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Just Lost Coverage_iLve1TqfmhBdUgdFiV8j_2_d34x7k1w1jh" value="Just Lost Coverage" type="radio"
data-q="do_you_or_anyone_in_your_household_applying_for_coverage_have_medicare,_medicaid_or_va_coverage?" data-required="true"><label style="margin-left:10px;margin-bottom:0;"
for="Just Lost Coverage_iLve1TqfmhBdUgdFiV8j_2_d34x7k1w1jh">Just Lost Coverage</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#0026FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>We are here to help:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-itBEGkVTQnNqQ1vEi93T" class="form-builder--item-input form-builder--item"><!----><label>Please provide the date you lost coverage: <span>*</span></label><input type="text" placeholder="MM/DD/YYYY"
name="itBEGkVTQnNqQ1vEi93T" class="form-control" id="itBEGkVTQnNqQ1vEi93T" data-q="date_you_lost_coverage" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1100FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Tell us about your current employment status:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">What is your employment status? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Employed_U87bnaSID9SZT1wa9O0J_0_d34x7k1w1jh" value="Employed" type="radio" data-q="what_is_your_employment_status?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Employed_U87bnaSID9SZT1wa9O0J_0_d34x7k1w1jh">Employed</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Unemployed_U87bnaSID9SZT1wa9O0J_1_d34x7k1w1jh" value="Unemployed" type="radio" data-q="what_is_your_employment_status?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Unemployed_U87bnaSID9SZT1wa9O0J_1_d34x7k1w1jh">Unemployed</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-SXSFzpqKFdfOdIIRGtvN" class="form-builder--item-input form-builder--item"><!----><label>What is your Employer Name? <span>*</span></label><input type="text" placeholder="Company Name" name="SXSFzpqKFdfOdIIRGtvN"
class="form-control" id="SXSFzpqKFdfOdIIRGtvN" data-q="what_is_your_employer_name?" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>What is your Employer phone number? <span>*</span></label><input placeholder="Company Phone #" name="JoZR7PELsdSaOpzVzXwX"
type="number" step="any" class="form-control" data-q="what_is_your_employer_phone_number?" data-required="true"><!----><!----></div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Who do you say you're supporting on your tax forms? <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="TMoXNzfsQxfV9UUrTOqy" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Myself</span><!--]--></span><!--v-if-->
</li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Myself + Spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Myself + Dependent(s)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Myself + Spouse + Dependent(s)</span><!--]--></span><!--v-if--></li>
<!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:15px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><strong>READ CLOSELY</strong></p>
<ul>
<li>
<p><strong>You</strong> = 1</p>
</li>
<li>
<p><strong>Spouse</strong> = 1</p>
</li>
<li>
<p><strong>Dependents</strong> you claim on your taxes(Ie, children, parents you pay for their cost of living, adopted family members) = 1 each</p>
</li>
</ul>
</div>
</div>
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1E00FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>To qualify for $0 Health Coverage you must make below $1,822 per month.</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Please Select Your Monthly Income: <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="1a9kypQ0qz8t7pe26Gq1" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,215 -
$1,299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,300 - $1,399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,400 - $1,499</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,500 - $1,599</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,600 - $1,699</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,700 - $1,799</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,800 - $1,822</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1500FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>To qualify for $0 Health Coverage you must make below $2,465 combined per month:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>What is your current monthly income? (Spouse NOT Included) <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="8LY3nebthqpzehSrrIbT" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$0 - $99</span><!--]--></span><!--v-if-->
</li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$100 - $199</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$200 - $299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$300 - $399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$400 - $499</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$500 - $599</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$600 - $699</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-7" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$700 - $799</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-8" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$800 - $899</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-9" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$900 - $999</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-10" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,000 - $1,099</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-11" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,100 - $1,199</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-12" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,200 - $1,299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-13" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,300 - $1,399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-14" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,400 - $1,499</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-15" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,500 - $1,599</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-16" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,600 - $1,699</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-17" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,700 - $1,799</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-18" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,800 - $1,899</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-19" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,900 - $1,999</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-20" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,000 - $2,099</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-21" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,100 - $2,199</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-22" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,200 - $2,299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-23" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,300 - $2,399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-24" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,400 - $2,465</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>What is your Spouses monthly income? <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="YHJhCzZWTGfCTozw2VrR" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>S0 -$99</span><!--]--></span><!--v-if-->
</li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$100 - $199</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$200 - $299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$300 - $399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$400 - $499</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$500 - $599</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$600 - $699</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-7" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$700 - $799</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-8" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$800 - $899</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-9" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$900 - $999</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-10" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,000 - $1,099</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-11" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,100 - $1,199</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-12" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,200 - $1,299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-13" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,300 - $1,399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-14" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,400 - $1,499</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-15" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,500 - $1,599</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-16" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,600 - $1,699</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-17" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,700 - $1,799</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-18" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,800 - $1,899</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-19" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$1,900 - $1,999</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-20" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,000 - $2,099</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-21" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,100 - $2,199</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-22" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,200 - $2,299</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-23" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,300 - $2,399</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-24" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>$2,400 - $2,465</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-cKQ0FQkRN8i7cXPaZrAf" class="form-builder--item-input form-builder--item"><!----><label>Spouse's Employer Name <!----></label><input type="text" placeholder="Required if your spouse has an income"
name="cKQ0FQkRN8i7cXPaZrAf" class="form-control" id="cKQ0FQkRN8i7cXPaZrAf" data-q="spouse's_employer_name" data-required="false"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div data-v-fd05e6d5="">
<div class="form-builder--item-input form-builder--item field-container"><!----><label>Spouse's Employer Phone Number <!----></label>
<div class="flex phone-input" style=""><input type="tel" name="KcUJcIcYhS1zzDxTUXWU" placeholder="" autocomplete="off" class="form-control" data-q="spouse's_employer_phone_number" data-required="false"><!----></div>
<!----><!----><!----><!----><!---->
</div>
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><strong>IMPORTANT:</strong> You and your spouse cannot make more than $2,465 per month combined. Please verify before continuing</p>
</div>
</div>
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1500FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>To be eligible for $0 Health Coverage, your income must be within the specified range, which varies based on your family size.</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--img-wrap" style="justify-content:center;" data-v-fd05e6d5="">
<div class="form-builder--item form-builder--image"><img class="hl-un-optimized mw-100"
src="https://images.leadconnectorhq.com/image/f_webp/q_85/r_1000/u_https://storage.googleapis.com/highlevel-backend.appspot.com/location/ZEgBOYA0NimImViHQngi/form/kyYG207kEsnPSNPJXQxn/16e6bce5-13d1-4e6f-9d67-629c8fad4682.png"
style="width:300px;height:100%;" loading="lazy"></div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label>What is your current monthly income? (Dependent(s) NOT included) <span>*</span></label>
<div class="input-group">
<div class="input-group-prepend"><span class="input-group-text">$</span></div><input placeholder="" name="fqsJzYVkGoybHVpeingm" type="text" class="form-control" data-q="what_is_your_current_monthly_income?_(dependent(s)_not_included)"
data-required="true">
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1E00FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>To be eligible for $0 Health Coverage, your income must be within the specified range, which varies based on your family size.</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--img-wrap" style="justify-content:center;" data-v-fd05e6d5="">
<div class="form-builder--item form-builder--image"><img class="hl-un-optimized mw-100"
src="https://images.leadconnectorhq.com/image/f_webp/q_85/r_1000/u_https://storage.googleapis.com/highlevel-backend.appspot.com/location/ZEgBOYA0NimImViHQngi/form/kyYG207kEsnPSNPJXQxn/2c8a76c7-637b-4e8f-9b12-a718e93d6ace.png"
style="width:300px;height:100%;" loading="lazy"></div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label>What is your current monthly income? (Spouse & Dependent(s) NOT included) <span>*</span></label>
<div class="input-group">
<div class="input-group-prepend"><span class="input-group-text">$</span></div><input placeholder="" name="8f26oxxzv9y5Zh3rq0QE" type="text" class="form-control"
data-q="what_is_your_current_monthly_income?_(spouse_&_dependent(s)_not_included)" data-required="true">
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label>What is your spouse's monthly income? (Sole Income Only) <span>*</span></label>
<div class="input-group">
<div class="input-group-prepend"><span class="input-group-text">$</span></div><input placeholder="" name="pTgO2eu4CXNptkVmdAYD" type="text" class="form-control" data-q="what_is_your_spouse's_monthly_income?_(sole_income_only)"
data-required="true">
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#040CFFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><strong>You must complete the information below even if you are not wanting to enroll them in a plan.</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-uwfOugmgzbgUdv4PVBrJ" class="form-builder--item-input form-builder--item"><!----><label>Spouse Legal First Name <span>*</span></label><input type="text" placeholder="Spouse Legal First Name" name="uwfOugmgzbgUdv4PVBrJ"
class="form-control" id="uwfOugmgzbgUdv4PVBrJ" data-q="spouse_legal_first_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-9vsCrjro1ToJVo9djk8B" class="form-builder--item-input form-builder--item"><!----><label>Spouse Legal Last Name <!----></label><input type="text" placeholder="Spouse Legal Last Name" name="9vsCrjro1ToJVo9djk8B"
class="form-control" id="9vsCrjro1ToJVo9djk8B" data-q="spouse_legal_last_name" data-required="false"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-wk7c4OB3RW99aq74bEJe" class="form-builder--item-input form-builder--item"><!----><label>Spouse's Date of Birth MM-DD-YYYY <span>*</span></label><input type="text" placeholder="MM-DD-YYYY" name="wk7c4OB3RW99aq74bEJe"
class="form-control" id="wk7c4OB3RW99aq74bEJe" data-q="spouse's_date_of_birth_mm-dd-yyyy" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><label class="item-description"></label><label>Spouse's Gender <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="iMJtbmU7rQGlJdc6tueD" type="text" autocomplete="off" spellcheck="false" placeholder="Select your spouse gender" style="width:0;position:absolute;padding:0;"
value="" tabindex="0" class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[-->Select your spouse gender<!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Male</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Female</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you want us to enroll your spouse? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_Errcg7BsPNvaIUFCVqyi_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_want_us_to_enroll_your_spouse?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_Errcg7BsPNvaIUFCVqyi_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_Errcg7BsPNvaIUFCVqyi_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_want_us_to_enroll_your_spouse?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_Errcg7BsPNvaIUFCVqyi_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#0800FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Next, we need to check program eligibility for your spouse:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-9tlPWBzy7LIcxQ4VEj2L" class="form-builder--item-input form-builder--item"><!----><label>Spouse Social Security Number <span>*</span></label><input type="text" placeholder="xxx-xx-xxx" name="9tlPWBzy7LIcxQ4VEj2L"
class="form-control" id="9tlPWBzy7LIcxQ4VEj2L" data-q="spouse_social_security_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000FF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:15px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><em>This is required by Healthcare.gov to verify your spouses identity.</em></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--img-wrap" style="justify-content:center;" data-v-fd05e6d5="">
<div class="form-builder--item form-builder--image"><img class="hl-un-optimized mw-100"
src="https://images.leadconnectorhq.com/image/f_webp/q_85/r_1000/u_https://storage.googleapis.com/highlevel-backend.appspot.com/location/ZEgBOYA0NimImViHQngi/form/kyYG207kEsnPSNPJXQxn/6f7dcbe4-2bf2-4209-9bdc-316c8c7afaf3.png"
style="width:100px;height:100%;" loading="lazy"></div>
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you have Any Dependents? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_pVaLk2J2ZPUj9KVsmA1f_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_have_any_dependents?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_pVaLk2J2ZPUj9KVsmA1f_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_pVaLk2J2ZPUj9KVsmA1f_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_have_any_dependents?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_pVaLk2J2ZPUj9KVsmA1f_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#0800FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p><strong>You must complete the information below even if you are not wanting to enroll them in a plan.</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-idCNoSZviUBTCrGqSV6Q" class="form-builder--item-input form-builder--item"><!----><label>Dependent 1st Full Legal Name <span>*</span></label><input type="text" placeholder="Enter your first dependent Full Legal Name"
name="idCNoSZviUBTCrGqSV6Q" class="form-control" id="idCNoSZviUBTCrGqSV6Q" data-q="dependent_1_full_legal_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Dependent 1st Gender <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="9IDhr7fzVLcFZcU7duJi" type="text" autocomplete="off" spellcheck="false" placeholder="Select your first dependent gender"
style="width:0;position:absolute;padding:0;" value="" tabindex="0" class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[-->Select your first dependent gender<!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Male</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Female</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-E901KT4aqvHtorhzaPuh" class="form-builder--item-input form-builder--item"><!----><label>Dependent 1st Date of Birth MM-DD-YYYY <span>*</span></label><input type="text" placeholder="MM-DD-YYYY" name="E901KT4aqvHtorhzaPuh"
class="form-control" id="E901KT4aqvHtorhzaPuh" data-q="dependent_1st_date_of_birth_mm-dd-yyyy" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Relationship to dependent 1 <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="fc0UqYA628MkoOWJjWkU" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent (including adoptive parents)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother or Sister (including half and
step-siblings)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-7" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Uncle or Aunt</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-8" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Nephew or Niece</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-9" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Cousin</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-10" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Adopted Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-11" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-12" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Parent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-13" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Son-in-law or Daughter-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-14" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother-in-law or Sister-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-15" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Mother-in-law or Father-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-16" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ward</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-17" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Former Spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-18" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Sponsored Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-19" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Dependent of a Minor Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-20" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ex-spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-21" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-22" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Court Appointed Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-23" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Collateral Dependnet</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-24" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Life Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-25" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Annultant</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-26" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Trustee</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-27" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relationship</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-28" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relative (including by marriage and
adoption)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-29" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent's Domestic Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-30" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child of Domestic Partner (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-31" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Unknown</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you want to enroll dependent 1? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_DFxUllSZtS2BIDycXJHA_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_want_to_enroll_dependent_1?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_DFxUllSZtS2BIDycXJHA_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_DFxUllSZtS2BIDycXJHA_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_want_to_enroll_dependent_1?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_DFxUllSZtS2BIDycXJHA_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1500FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>Next, we need to check program eligibility for your dependents:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-shHeBAuREUcBmuUv78G0" class="form-builder--item-input form-builder--item"><!----><label>Dependent 1st Social Security Number <span>*</span></label><input type="text" placeholder="xxx-xx-xxx" name="shHeBAuREUcBmuUv78G0"
class="form-control" id="shHeBAuREUcBmuUv78G0" data-q="dependent_1st_social_securities_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:14px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><em>This is required by Healthcare.gov to verify your dependents identity.</em></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--img-wrap" style="justify-content:center;" data-v-fd05e6d5="">
<div class="form-builder--item form-builder--image"><img class="hl-un-optimized mw-100"
src="https://images.leadconnectorhq.com/image/f_webp/q_85/r_1000/u_https://storage.googleapis.com/highlevel-backend.appspot.com/location/ZEgBOYA0NimImViHQngi/form/kyYG207kEsnPSNPJXQxn/571a236e-fe66-4062-aed2-92312952590f.png"
style="width:100px;height:100%;" loading="lazy"></div>
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you have a 2nd Dependent? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_mSn6kBdv9JNgZvplQXlI_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_have_a_2nd_dependent?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_mSn6kBdv9JNgZvplQXlI_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_mSn6kBdv9JNgZvplQXlI_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_have_a_2nd_dependent?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_mSn6kBdv9JNgZvplQXlI_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>You must complete the information below even if you are not wanting to enroll them in a plan.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-bv7KkTeaOASbblKUV92L" class="form-builder--item-input form-builder--item"><!----><label>Dependent 2nd Full Legal Name <span>*</span></label><input type="text" placeholder="Enter your 2nd dependent Full Legal Name"
name="bv7KkTeaOASbblKUV92L" class="form-control" id="bv7KkTeaOASbblKUV92L" data-q="dependent_2nd_full_legal_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Dependent 2nd Gender <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="WzeKq2uhdCqvkDtRzFix" type="text" autocomplete="off" spellcheck="false" placeholder="Enter your 2nd dependent gender"
style="width:0;position:absolute;padding:0;" value="" tabindex="0" class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[-->Enter your 2nd dependent gender<!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Male</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Female</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label style="" for="3a09-2443-NativeDatePicker" id="3a09-2443-label">Dependent 2nd Date of Birth MM-DD-YYYY <span>*</span></label>
<div class="vdpWithInput vdpComponent date-picker-custom-style date-picker-field-survey" name="NCZh4pFOqjQxzMTXiklF"><input value="" placeholder="MM-DD-YYYY" type="text" data-q="dependent_2nd_date_of_birth_mm-dd-yyyy"
data-required="true"><!----><!----></div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label> Relationship To Dependent 2 <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="5PYfbLymICEEmSbkZumU" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent (including adoptive parents)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother or Sister (including half and
step-siblings)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-7" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Uncle or Aunt</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-8" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Nephew or Niece</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-9" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Cousin</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-10" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Adopted Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-11" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-12" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Parent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-13" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Son-in-law or Daughter-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-14" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother-in-law or Sister-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-15" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Mother-in-law or Father-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-16" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ward</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-17" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Former Spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-18" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Sponsored Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-19" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Dependent of a Minor Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-20" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ex-spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-21" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-22" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Court Appointed Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-23" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Collateral Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-24" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Life Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-25" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Annultant</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-26" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Trustee</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-27" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relationship</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-28" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relative (including by marriage and
adoption)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-29" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent's Domestic Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-30" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child of Domestic Partner (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-31" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Unknown</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you want to enroll dependent 2? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_KwxSqUdwlnYPKxi0iyYN_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_want_to_enroll_dependent_2?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_KwxSqUdwlnYPKxi0iyYN_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_KwxSqUdwlnYPKxi0iyYN_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_want_to_enroll_dependent_2?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_KwxSqUdwlnYPKxi0iyYN_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-4t4m0vkkOCh5x3QcEmDB" class="form-builder--item-input form-builder--item"><!----><label>Dependent 2nd Social Security Number <span>*</span></label><input type="text" placeholder="xxx-xx-xxx" name="4t4m0vkkOCh5x3QcEmDB"
class="form-control" id="4t4m0vkkOCh5x3QcEmDB" data-q="dependent_2nd_social_securities_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!----><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you have a 3rd Dependent? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_m3pCZezKJb66TKwYyR0b_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_have_3rd_dependent?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_m3pCZezKJb66TKwYyR0b_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_m3pCZezKJb66TKwYyR0b_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_have_3rd_dependent?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_m3pCZezKJb66TKwYyR0b_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>You must complete the information below even if you are not wanting to enroll them in a plan.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-mXyyc8ZbtZRTr7OacHYP" class="form-builder--item-input form-builder--item"><!----><label>Dependent 3rd Full Legal Name <span>*</span></label><input type="text" placeholder="Enter your 3rd dependent's full legal name"
name="mXyyc8ZbtZRTr7OacHYP" class="form-control" id="mXyyc8ZbtZRTr7OacHYP" data-q="dependent_3rd_full_legal_name_*" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Dependent 3rd Gender <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="Q2Qjt97VumA2noJ6B3Lp" type="text" autocomplete="off" spellcheck="false" placeholder="Enter your 3rd dependent's gender"
style="width:0;position:absolute;padding:0;" value="" tabindex="0" class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[-->Enter your 3rd dependent's gender<!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Male</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Female</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label style="" for="ecf1-4b65-NativeDatePicker" id="ecf1-4b65-label">Dependent 3rd Date of Birth MM-DD-YYYY <span>*</span></label>
<div class="vdpWithInput vdpComponent date-picker-custom-style date-picker-field-survey" name="4etdGsnueWlzrJQJvKuz"><input value="" placeholder="MM-DD-YYYY" type="text" data-q="dependent_3rd_date_of_birth_mm-dd-yyyy"
data-required="true"><!----><!----></div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Relationship To Dependent 3 <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="xyUrdeB0KHOs1qSF4rp7" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent (including adoptive parents)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother or Sister (including half and
step-siblings)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-7" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Uncle or Aunt</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-8" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Nephew or Niece</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-9" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Cousin</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-10" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Adopted Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-11" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-12" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Parent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-13" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Son-in-law or Daughter-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-14" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother-in-law or Sister-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-15" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Mother-in-law or Father-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-16" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ward</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-17" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Former Spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-18" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Sponsored Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-19" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Dependent of a Minor Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-20" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ex-spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-21" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-22" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Court Appointed Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-23" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Collateral Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-24" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Life Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-25" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Annultant</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-26" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Trustee</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-27" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relationship</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-28" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relative (including by marriage and
adoption)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-29" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent's Domestic Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-30" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child of Domestic Partner (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-31" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Unknown</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you want to enroll dependent 3? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_HXJMlKOqWYA0CKczTaCn_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_want_to_enroll_dependent_3?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_HXJMlKOqWYA0CKczTaCn_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_HXJMlKOqWYA0CKczTaCn_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_want_to_enroll_dependent_3?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_HXJMlKOqWYA0CKczTaCn_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-fqsZI7EZ2rfkOyKwUOzK" class="form-builder--item-input form-builder--item"><!----><label>Dependent 3rd Social Security Number <span>*</span></label><input type="text" placeholder="xxx-xx-xxx" name="fqsZI7EZ2rfkOyKwUOzK"
class="form-control" id="fqsZI7EZ2rfkOyKwUOzK" data-q="dependent_3rd_social_securities_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!----><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you have a 4th Dependent? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_6HkslRtk1vrEBULU0N6L_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_have_a_4th_dependent?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_6HkslRtk1vrEBULU0N6L_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_6HkslRtk1vrEBULU0N6L_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_have_a_4th_dependent?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_6HkslRtk1vrEBULU0N6L_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>You must complete the information below even if you are not wanting to enroll them in a plan.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-WbQydID5isxDAolCcTxv" class="form-builder--item-input form-builder--item"><!----><label>Dependent 4th Full Legal Name <span>*</span></label><input type="text" placeholder="Enter your 4th dependent full legal name"
name="WbQydID5isxDAolCcTxv" class="form-control" id="WbQydID5isxDAolCcTxv" data-q="dependent_4th_full_legal_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Dependent 4th Gender <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="kEbCHdLTq9ihJ5ujnpIv" type="text" autocomplete="off" spellcheck="false" placeholder="Select your 4th dependent gender"
style="width:0;position:absolute;padding:0;" value="" tabindex="0" class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[-->Select your 4th dependent gender<!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Male</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Female</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-fdFb0NMDhsvnkj70YcGs" class="form-builder--item-input form-builder--item"><!----><label>Dependent 4th Date of Birth MM-DD-YYYY <span>*</span></label><input type="text" placeholder="MM-DD-YYYY" name="fdFb0NMDhsvnkj70YcGs"
class="form-control" id="fdFb0NMDhsvnkj70YcGs" data-q="dependent_4th_date_of_birth_mm-dd-yyyy" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label> Relationship To Dependent 4 <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="oqNTgn0k5WOFAHCTTL1u" type="text" autocomplete="off" spellcheck="false" placeholder="" style="width:0;position:absolute;padding:0;" value="" tabindex="0"
class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[--><!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent (including adoptive parents)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-2" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-3" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Stepchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-4" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandparent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-5" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Grandchild</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-6" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother or Sister (including half and
step-siblings)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-7" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Uncle or Aunt</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-8" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Nephew or Niece</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-9" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Cousin</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-10" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Adopted Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-11" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Child</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-12" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Foster Parent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-13" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Son-in-law or Daughter-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-14" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Brother-in-law or Sister-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-15" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Mother-in-law or Father-in-law</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-16" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ward</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-17" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Former Spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-18" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Sponsored Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-19" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Dependent of a Minor Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-20" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Ex-spouse</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-21" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-22" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Court Appointed Guardian</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-23" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Collateral Dependent</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-24" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Life Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-25" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Annultant</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-26" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Trustee</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-27" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relationship</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-28" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Other Relative (including by marriage and
adoption)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-29" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Parent's Domestic Partner</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-30" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Child of Domestic Partner (including adopted
children)</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-31" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Unknown</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you want to enroll dependent 4 <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_d4Om5m8t6sRhkwzagZsk_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_want_to_enroll_dependent_4" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_d4Om5m8t6sRhkwzagZsk_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_d4Om5m8t6sRhkwzagZsk_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_want_to_enroll_dependent_4" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_d4Om5m8t6sRhkwzagZsk_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-RZBn9cEL27dmT7WQeXFv" class="form-builder--item-input form-builder--item"><!----><label>Dependent 4th Social Security Number <span>*</span></label><input type="text" placeholder="xxx-xx-xxx" name="RZBn9cEL27dmT7WQeXFv"
class="form-control" id="RZBn9cEL27dmT7WQeXFv" data-q="dependent_4th_social_securities_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!----><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you have a 5th Dependent? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_oJRLHVXqvtI8YUeogxUX_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_have_a_5th_dependent?_*" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_oJRLHVXqvtI8YUeogxUX_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_oJRLHVXqvtI8YUeogxUX_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_have_a_5th_dependent?_*" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_oJRLHVXqvtI8YUeogxUX_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>You must complete the information below even if you are not wanting to enroll them in a plan.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-NuSEySdaXRMJKsEliXwM" class="form-builder--item-input form-builder--item"><!----><label>Dependent 5 Full Legal Name <span>*</span></label><input type="text" placeholder="Enter your 5th dependent full legal name"
name="NuSEySdaXRMJKsEliXwM" class="form-control" id="NuSEySdaXRMJKsEliXwM" data-q="dependent_5_full_legal_name" data-required="true"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item field-container form-builder--item-input" data-v-fd05e6d5=""><!----><label>Dependent 5th Gender <span>*</span></label>
<div tabindex="-1" class="multiselect multi_select_form" role="combobox" aria-owns="listbox-null"><!--[-->
<div class="multiselect__select"></div><!--]--><!--[--><!--]-->
<div class="multiselect__tags"><!--[-->
<div class="multiselect__tags-wrap" style="display:none;"><!--[--><!--]--></div><!--v-if--><!--]-->
<div class="multiselect__spinner" style="display:none;"></div><input name="95qFID4mBOjYsRtp1anT" type="text" autocomplete="off" spellcheck="false" placeholder="Select your 5th dependent gender"
style="width:0;position:absolute;padding:0;" value="" tabindex="0" class="multiselect__input" aria-controls="listbox-null"><!--v-if--><span class="multiselect__placeholder"><!--[-->Select your 5th dependent gender<!--]--></span>
</div>
<div class="multiselect__content-wrapper" tabindex="-1" style="max-height:300px;display:none;">
<ul class="multiselect__content" style="display:inline-block;" role="listbox" id="listbox-null"><!--[--><!--]--><!--v-if--><!--[-->
<li class="multiselect__element" id="null-0" role="option"><span class="multiselect__option--highlight multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Male</span><!--]--></span><!--v-if--></li>
<li class="multiselect__element" id="null-1" role="option"><span class="multiselect__option" data-select="" data-selected="" data-deselect=""><!--[--><span>Female</span><!--]--></span><!--v-if--></li><!--]-->
<li style="display:none;"><span class="multiselect__option"><!--[-->No elements found. Consider changing the search query.<!--]--></span></li>
<li style="display:none;"><span class="multiselect__option"><!--[-->List is empty.<!--]--></span></li><!--[--><!--]-->
</ul>
</div>
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label style="" for="ca49-5e0e-NativeDatePicker" id="ca49-5e0e-label">Dependent 5th Date of Birth MM-DD-YYYY <span>*</span></label>
<div class="vdpWithInput vdpComponent date-picker-custom-style date-picker-field-survey" name="PlGjGx0uWNsBCNirvuOa"><input value="" placeholder="MM-DD-YYYY" type="text" data-q="dependent_5th_date_of_birth_mm-dd-yyyy"
data-required="true"><!----><!----></div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you want to enroll dependent 5 <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_emFf7YmokWum8cCj6EKL_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_want_to_enroll_dependent_5" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_emFf7YmokWum8cCj6EKL_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_emFf7YmokWum8cCj6EKL_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_want_to_enroll_dependent_5" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_emFf7YmokWum8cCj6EKL_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-9qavGZmadDCc34Kin96L" class="form-builder--item-input form-builder--item"><!----><label>Dependent 5th Social Security Number <span>*</span></label><input type="text" placeholder="xxx-xx-xxx" name="9qavGZmadDCc34Kin96L"
class="form-control" id="9qavGZmadDCc34Kin96L" data-q="dependent_5th_social_securities_number" data-required="true"><!----><!----><!----></div>
</div>
</div><!----><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">Do you have a doctor you would like to keep? <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Yes_4HQ2YXJEFByN65vcdRns_0_d34x7k1w1jh" value="Yes" type="radio" data-q="do_you_have_a_doctor_you_would_like_to_keep?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="Yes_4HQ2YXJEFByN65vcdRns_0_d34x7k1w1jh">Yes</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="No_4HQ2YXJEFByN65vcdRns_1_d34x7k1w1jh" value="No" type="radio" data-q="do_you_have_a_doctor_you_would_like_to_keep?" data-required="true"><label
style="margin-left:10px;margin-bottom:0;" for="No_4HQ2YXJEFByN65vcdRns_1_d34x7k1w1jh">No</label></div>
</div><!--]--><!----><!----><!---->
</div><!---->
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-UmWFs8IL4euljwWQbSfq" class="form-builder--item-input form-builder--item"><!----><label>Doctor's Name <!----></label><input type="text" placeholder="" name="UmWFs8IL4euljwWQbSfq" class="form-control"
id="UmWFs8IL4euljwWQbSfq" data-q="doctor's_name" data-required="false"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-TtS2ShhLoxAE7nOaz7Lh" class="form-builder--item-input form-builder--item"><!----><label>Doctor's City <!----></label><input type="text" placeholder="" name="TtS2ShhLoxAE7nOaz7Lh" class="form-control"
id="TtS2ShhLoxAE7nOaz7Lh" data-q="doctor's_city" data-required="false"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5="">
<div data-v-fd05e6d5="">
<div class="field-container">
<div id="form-Dyt7HDakoDwpOzowDH3H" class="form-builder--item-input form-builder--item"><!----><label>Doctor's State <!----></label><input type="text" placeholder="" name="Dyt7HDakoDwpOzowDH3H" class="form-control"
id="Dyt7HDakoDwpOzowDH3H" data-q="doctor's_state" data-required="false"><!----><!----><!----></div>
</div>
</div><!---->
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div><!--]-->
</div>
</div>
<div class="form-builder--wrap-questions ghl-question" data-v-fd05e6d5="">
<div class="fields-container row" data-v-fd05e6d5=""><!--[-->
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#1E00FFFF;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:20px;font-weight:400;text-align:left;padding:0px 20px 0px 20px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p style="text-align: center"><strong>You made it to the last page, please sign below to finalize your program submission:</strong></p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like
Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and
premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit. <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Agree_2eERVJkuQUnaDL1RQ33y_0_d34x7k1w1jh" value="Agree" type="radio"
data-q="i_understand_that_i’m_not_eligible_for_a_premium_tax_credit_if_i’m_found_eligible_for_other_qualifying_health_coverage,_like_medicaid,_children's_health_insurance_program_(chip),_or_a_job-based_health_plan._i_also_understand_that_if_i_become_eligible_for_other_qualifying_health_coverage,_i_must_contact_the_marketplace_to_end_my_marketplace_coverage_and_premium_tax_credit._if_i_don’t,_the_person_who_files_taxes_in_my_household_may_need_to_pay_back_my_premium_tax_credit."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Agree_2eERVJkuQUnaDL1RQ33y_0_d34x7k1w1jh">Agree</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Disagree_2eERVJkuQUnaDL1RQ33y_1_d34x7k1w1jh" value="Disagree" type="radio"
data-q="i_understand_that_i’m_not_eligible_for_a_premium_tax_credit_if_i’m_found_eligible_for_other_qualifying_health_coverage,_like_medicaid,_children's_health_insurance_program_(chip),_or_a_job-based_health_plan._i_also_understand_that_if_i_become_eligible_for_other_qualifying_health_coverage,_i_must_contact_the_marketplace_to_end_my_marketplace_coverage_and_premium_tax_credit._if_i_don’t,_the_person_who_files_taxes_in_my_household_may_need_to_pay_back_my_premium_tax_credit."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Disagree_2eERVJkuQUnaDL1RQ33y_1_d34x7k1w1jh">Disagree</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">The Centers for Medicaid & Medicare Services (CMS) now requires two forms of consent from our clients. You have already
completed the first form of consent. Please read the attestations and sign that you understand. Select whether you agree or disagree to adhere to Marketplace regulations. Each year we inform you that you must file your taxes, how
eligibility works, and how tax credits are reconciled. Please note that we cannot enroll you without your consent. Disagreeing with any of the below attestations may hinder the ability to enroll in a plan. Please ask
your agent if you need further explanation on any of the following. I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: • I must file a
federal income tax return for the 2024 tax year. • If I’m married at the end of 2024 , I must file a joint income tax return with my spouse. I also expect that: • No one else will be able to claim me as a dependent on their 2024
federal income tax return. • I’ll claim a personal exemption deduction on my 2024 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose
premium for coverage is paid in whole or in part by advance payments of the premium tax credit. If any of the above changes: • I understand that it may impact my ability to get the premium tax credit. • I also understand that when I
file my 2024 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income
on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.
<span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Agree_VOqSsCg0bfkF5SE6xuiJ_0_d34x7k1w1jh" value="Agree" type="radio"
data-q="the_centers_for_medicaid_&_medicare_services_(cms)_now_requires_two_forms_of_consent_from_our_clients._you_have_already_completed_the_first_form_of_consent._please_read_the_attestations_and_sign_that_you_understand._select_whether_you_agree_or_disagree_to_adhere_to_marketplace_regulations._each_year_we_inform_you_that_you_must_file_your_taxes,_how_eligibility_works,_and_how_tax_credits_are_reconciled._ _please_note_that we_cannot_enroll_you_without_your_consent. disagreeing_with_any_of_the_below_attestations_may_hinder_the_ability_to_enroll_in_a_plan._please_ask_your_agent_if_you_need_further_explanation_on_any_of_the_following._i_understand_that_because_the_premium_tax_credit_will_be_paid_on_my_behalf_to_reduce_the_cost_of_health_coverage_for_myself_and/or_my_dependents:_•_i_must_file_a_federal_income_tax_return_for_the_2024_tax_year._•_if_i’m_married_at_the_end_of_2024_,_i_must_file_a_joint_income_tax_return_with_my_spouse._i_also_expect_that:_•_no_one_else_will_be_able_to_claim_me_as_a_dependent_on_their_2024_federal_income_tax_return._•_i’ll_claim_a_personal_exemption_deduction_on_my_2024_federal_income_tax_return_for_any_individual_listed_on_this_application_as_my_dependent_who_is_enrolled_in_coverage_through_this_marketplace,_and_whose_premium_for_coverage_is_paid_in_whole_or_in_part_by_advance_payments_of_the_premium_tax_credit._if_any_of_the_above_changes:_•_i_understand_that_it_may_impact_my_ability_to_get_the_premium_tax_credit._•_i_also_understand_that_when_i_file_my_2024_federal_income_tax_return,_the_internal_revenue_service_(irs)_will_compare_the_income_on_my_tax_return_with_the_income_on_my_application._i_understand_that_if_the_income_on_my_tax_return_is_lower_than_the_amount_of_income_on_my_application,_i_may_be_eligible_to_get_an_additional_premium_tax_credit_amount._on_the_other_hand,_if_the_income_on_my_tax_return_is_higher_than_the_amount_of_income_on_my_application,_i_may_owe_additional_federal_income_tax."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Agree_VOqSsCg0bfkF5SE6xuiJ_0_d34x7k1w1jh">Agree</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Disagree_VOqSsCg0bfkF5SE6xuiJ_1_d34x7k1w1jh" value="Disagree" type="radio"
data-q="the_centers_for_medicaid_&_medicare_services_(cms)_now_requires_two_forms_of_consent_from_our_clients._you_have_already_completed_the_first_form_of_consent._please_read_the_attestations_and_sign_that_you_understand._select_whether_you_agree_or_disagree_to_adhere_to_marketplace_regulations._each_year_we_inform_you_that_you_must_file_your_taxes,_how_eligibility_works,_and_how_tax_credits_are_reconciled._ _please_note_that we_cannot_enroll_you_without_your_consent. disagreeing_with_any_of_the_below_attestations_may_hinder_the_ability_to_enroll_in_a_plan._please_ask_your_agent_if_you_need_further_explanation_on_any_of_the_following._i_understand_that_because_the_premium_tax_credit_will_be_paid_on_my_behalf_to_reduce_the_cost_of_health_coverage_for_myself_and/or_my_dependents:_•_i_must_file_a_federal_income_tax_return_for_the_2024_tax_year._•_if_i’m_married_at_the_end_of_2024_,_i_must_file_a_joint_income_tax_return_with_my_spouse._i_also_expect_that:_•_no_one_else_will_be_able_to_claim_me_as_a_dependent_on_their_2024_federal_income_tax_return._•_i’ll_claim_a_personal_exemption_deduction_on_my_2024_federal_income_tax_return_for_any_individual_listed_on_this_application_as_my_dependent_who_is_enrolled_in_coverage_through_this_marketplace,_and_whose_premium_for_coverage_is_paid_in_whole_or_in_part_by_advance_payments_of_the_premium_tax_credit._if_any_of_the_above_changes:_•_i_understand_that_it_may_impact_my_ability_to_get_the_premium_tax_credit._•_i_also_understand_that_when_i_file_my_2024_federal_income_tax_return,_the_internal_revenue_service_(irs)_will_compare_the_income_on_my_tax_return_with_the_income_on_my_application._i_understand_that_if_the_income_on_my_tax_return_is_lower_than_the_amount_of_income_on_my_application,_i_may_be_eligible_to_get_an_additional_premium_tax_credit_amount._on_the_other_hand,_if_the_income_on_my_tax_return_is_higher_than_the_amount_of_income_on_my_application,_i_may_owe_additional_federal_income_tax."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Disagree_VOqSsCg0bfkF5SE6xuiJ_1_d34x7k1w1jh">Disagree</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to
use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt-out at any time. <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Agree_0kUn05dwRKZkeAB50l88_0_d34x7k1w1jh" value="Agree" type="radio"
data-q="to_make_it_easier_to_determine_my_eligibility_for_help_paying_for_coverage_in_future_years,_i_agree_to_allow_the_marketplace_to_use_my_income_data,_including_information_from_tax_returns,_for_the_next_5_years._the_marketplace_will_send_me_a_notice,_let_me_make_any_changes,_and_i_can_opt-out_at_any_time."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Agree_0kUn05dwRKZkeAB50l88_0_d34x7k1w1jh">Agree</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Disagree_0kUn05dwRKZkeAB50l88_1_d34x7k1w1jh" value="Disagree" type="radio"
data-q="to_make_it_easier_to_determine_my_eligibility_for_help_paying_for_coverage_in_future_years,_i_agree_to_allow_the_marketplace_to_use_my_income_data,_including_information_from_tax_returns,_for_the_next_5_years._the_marketplace_will_send_me_a_notice,_let_me_make_any_changes,_and_i_can_opt-out_at_any_time."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Disagree_0kUn05dwRKZkeAB50l88_1_d34x7k1w1jh">Disagree</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage
(like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t
stay enrolled in Marketplace coverage and have to pay full cost. Either I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation. Or I don’t give the Marketplace permission to
end Marketplace coverage in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay full cost for their Marketplace plan. <span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Agree_4kdaTKdzf5Fc5ftmkM0e_0_d34x7k1w1jh" value="Agree" type="radio"
data-q="if_anyone_on_your_application_is_enrolled_in_marketplace_coverage_and_is_later_found_to_have_other_qualifying_health_coverage_(like_medicare,_medicaid,_or_children's_health_insurance_program_(chip)),_the_marketplace_will_automatically_end_their_marketplace_plan_coverage._this_will_help_make_sure_that_anyone_who’s_found_to_have_other_qualifying_coverage_won’t_stay_enrolled_in_marketplace_coverage_and_have_to_pay_full_cost._either_i_agree_to_allow_the_marketplace_to_end_the_marketplace_coverage_of_the_people_on_my_application_in_this_situation._or_i_don’t_give_the_marketplace_permission_to_end_marketplace_coverage_in_this_situation._i_understand_that_the_affected_people_on_my_application_will_no_longer_be_eligible_for_financial_help_and_must_pay_full_cost_for_their_marketplace_plan."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Agree_4kdaTKdzf5Fc5ftmkM0e_0_d34x7k1w1jh">Agree</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Disagree_4kdaTKdzf5Fc5ftmkM0e_1_d34x7k1w1jh" value="Disagree" type="radio"
data-q="if_anyone_on_your_application_is_enrolled_in_marketplace_coverage_and_is_later_found_to_have_other_qualifying_health_coverage_(like_medicare,_medicaid,_or_children's_health_insurance_program_(chip)),_the_marketplace_will_automatically_end_their_marketplace_plan_coverage._this_will_help_make_sure_that_anyone_who’s_found_to_have_other_qualifying_coverage_won’t_stay_enrolled_in_marketplace_coverage_and_have_to_pay_full_cost._either_i_agree_to_allow_the_marketplace_to_end_the_marketplace_coverage_of_the_people_on_my_application_in_this_situation._or_i_don’t_give_the_marketplace_permission_to_end_marketplace_coverage_in_this_situation._i_understand_that_the_affected_people_on_my_application_will_no_longer_be_eligible_for_financial_help_and_must_pay_full_cost_for_their_marketplace_plan."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Disagree_4kdaTKdzf5Fc5ftmkM0e_1_d34x7k1w1jh">Disagree</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label class="field-label">I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make
changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household.
<span>*</span></label><!--[-->
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Agree_EBee07gs6hPzU4grl7ZY_0_d34x7k1w1jh" value="Agree" type="radio"
data-q="i_know_that_i_must_tell_the_program_i’ll_be_enrolled_in_if_information_i_listed_on_this_application_changes._i_know_i_can_make_changes_in_my_marketplace_account_or_by_calling_the_marketplace_call_center_at_1-800-318-2596_(tty:_1-855-889-4325)._i_know_a_change_in_my_information_could_affect_eligibility_for_member(s)_of_my_household."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Agree_EBee07gs6hPzU4grl7ZY_0_d34x7k1w1jh">Agree</label></div>
</div>
<div style="position:relative;display:inline-block;width:100%;" class="option-radio">
<div style="display:flex;align-items:baseline;margin-bottom:5px;"><input id="Disagree_EBee07gs6hPzU4grl7ZY_1_d34x7k1w1jh" value="Disagree" type="radio"
data-q="i_know_that_i_must_tell_the_program_i’ll_be_enrolled_in_if_information_i_listed_on_this_application_changes._i_know_i_can_make_changes_in_my_marketplace_account_or_by_calling_the_marketplace_call_center_at_1-800-318-2596_(tty:_1-855-889-4325)._i_know_a_change_in_my_information_could_affect_eligibility_for_member(s)_of_my_household."
data-required="true"><label style="margin-left:10px;margin-bottom:0;" for="Disagree_EBee07gs6hPzU4grl7ZY_1_d34x7k1w1jh">Disagree</label></div>
</div><!--]--><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:14px;font-weight:400;text-align:left;padding:0px 0px 0px 0px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>I hereby affirm that I have thoroughly reviewed and understood the contents of this <a target="_blank" rel="noopener noreferrer nofollow" href="https://nhacares.com/pp-nha-cares">attestation</a>. Consequently, I hereby authorize
Logan Holle to act in the capacity of my broker, representing both myself and the members of my household, specifically for the purpose of enrolling in a qualified Health Plan through the Federally Facilitated Marketplace.
Furthermore, I expressly consent to permit the aforementioned agent to access, view, and utilize my confidential information strictly for the purposes delineated herein.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:12px;font-weight:500;text-align:left;padding:0px 0px 0px 0px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>1. Search for an existing Marketplace Plan;</p>
<p>2. Complete an application for eligibility and enrollment in a Marketplace Plan;</p>
<p>3. Provide ongoing maintenance and enrollment assistance;</p>
<p>4. Respond to inquiries from the Marketplace regarding my application.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:12px;font-weight:400;text-align:left;padding:0px 0px 0px 0px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>I hereby declare that the information I have provided is both accurate and truthful for the purposes of my Marketplace Health Insurance Application. I affirm that I have read and agreed to the terms and conditions set forth, and
I understand that the agent specified earlier will securely store and utilize my Personally Identifiable Information (PII) solely for the purposes outlined above. By submitting this document, I also affirm compliance with the
income eligibility criteria as indicated in the chart below, assert that I am not a recipient of Medicare, Medicaid, or Employer Coverage, and declare that I do not use tobacco products, thereby making me eligible for Zero Premium
Health Coverage.</p>
<p style="text-align: start">I acknowledge that my consent is effective until such time as I withdraw it. Withdrawal of consent can be executed by sending an email to
<a target="_blank" rel="noopener noreferrer nofollow" href="mailto:logan@nhacares.com">logan@nhacares.com</a>.</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item heading-element" data-v-fd05e6d5="">
<div class="text-element"
style="color:#000000;background-color:#FFFFFF;border:0px none #FFFFFF;border-radius:0px;font-family:'Roboto';font-size:12px;font-weight:400;text-align:left;padding:0px 0px 0px 0px;box-shadow:0px 0px 0px 0px #FFFFFF;line-height:1.5;">
<div>
<p>By submitting your mobile number, you agree to receive texts, calls, and automated messages from Logan Holle. To opt-out, reply "STOP".</p>
</div>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item form-builder--item-input" data-v-fd05e6d5=""><!----><label style="" for="0bf4-1263-NativeDatePicker" id="0bf4-1263-label">Authorization Date <span>*</span></label>
<div class="vdpWithInput vdpComponent date-picker-custom-style date-picker-field-survey" name="R5NeG39MZlskBsUkMUQf"><input value="" placeholder="MM-DD-YYYY" type="text" data-q="authorization_date" data-required="true"><!----><!---->
</div><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div class="form-builder--item" data-v-fd05e6d5=""><!----><label>Authorization Signature <span>*</span></label>
<section class="signature-container">
<div style="width: 100%;"><canvas class="signature-button" style="min-height: 150px; touch-action: none; user-select: none;"></canvas></div><a aria-label="Clear" class="clear-button">Clear</a>
</section><!----><!----><!---->
</div>
<div class="field-divider" data-v-fd05e6d5=""></div>
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div data-v-fd05e6d5="" class="form-builder--item"><!---->
<div id="customHTML_html_iovcfze2zat3212-hl-custom-code">
<style type="text/css">
@import url("https://ghlcusomizer.s3.amazonaws.com/font_awesome/css/all_with_font.css");
:root {
--font-family: "KoHo";
/* CUSTOM FOOTER BUTTONS */
--button-bg: rgb(0, 124, 226);
--button-color: rgb(255, 255, 255);
--button-box-shadow: none;
--button-border-radius: 5px;
--button-font-size: 16px;
--button-font-weight: 700;
--button-text-transform: uppercase;
--button-padding: 8px 32px;
}
html {
scroll-behavior: smooth;
}
.ghl-footer {
display: none !important;
}
.fc_custom-survey-footer-container .fc_custom-survey-footer {
display: flex !important;
align-items: center !important;
justify-content: center !important;
padding: 1rem !important;
gap: 2px;
}
.fc_custom-survey-footer-container .fc_custom-survey-footer button {
box-shadow: var(--button-box-shadow) !important;
background-color: var(--button-bg);
font-family: var(--font-family) !important;
color: var(--button-color) !important;
border-radius: var(--button-border-radius) !important;
font-size: var(--button-font-size);
font-weight: var(--button-font-weight) !important;
padding: var(--button-padding) !important;
text-transform: var(--button-text-transform) !important;
transition: all 0.4s ease !important;
display: flex !important;
align-items: center !important;
gap: 8px !important;
}
.fc_custom-survey-footer-container .fc_custom-survey-footer button i {
font-family: "Font Awesome 5 Pro" !important;
margin-top: 1px !important;
}
</style>
<script>
(async function() {
const data = {
customButtons: {
isActive: true,
submitButtonText: "Submit",
submitButtonIcon: "far fa-check",
nextButtonText: "Next",
nextButtonIcon: "far fa-arrow-right",
prevButtonText: "Prev",
prevButtonIcon: "far fa-arrow-left",
},
};
//* HELPER FUNCTION
function getElementByFn(selector, type) {
let elements = [];
let intervalId;
return new Promise((res, rej) => {
intervalId = setInterval(() => {
elements = type === "multi" ? [...document.querySelectorAll(selector)] : document.querySelector(selector);
if (type === "multi" && !elements.length) return;
if (type === "single" && !elements) return;
clearInterval(intervalId);
return res(elements);
}, 300);
setTimeout(() => {
if (!elements) {
clearInterval(intervalId);
res(false);
console.log(`${selector} ${type} elements not found`);
}
clearInterval(intervalId);
}, 20000);
});
}
const debounce = (cb, delay = 1000) => {
let timeout;
return (...args) => {
clearTimeout(timeout);
timeout = setTimeout(() => cb(...args), delay);
};
};
// * Elements
const ghlSlidesContainer = await getElementByFn(".ghl-question-set");
const ghlSlides = [...ghlSlidesContainer.children];
const defaultFooter = await getElementByFn(".ghl-footer");
const parentContainer = defaultFooter.parentNode;
const customFooterContainer = document.createElement("div");
const customFooter = document.createElement("div");
const prevButton = document.createElement("button");
const nextButton = document.createElement("button");
const prevIcon = document.createElement("i");
const nextIcon = document.createElement("i");
customFooterContainer.className = "fc_custom-survey-footer-container";
customFooter.className = "fc_custom-survey-footer";
prevButton.className = "fc_custom-prev-btn";
nextButton.className = "fc_custom-next-btn";
prevIcon.className = data.customButtons.prevButtonIcon;
nextIcon.className = data.customButtons.nextButtonIcon;
// * Changing Text & Appending Icon on Button
prevButton.innerHTML = prevIcon.outerHTML + data.customButtons.prevButtonText;
nextButton.innerHTML = data.customButtons.nextButtonText + nextIcon.outerHTML;
// * Appending
customFooter.append(nextButton);
customFooterContainer.append(customFooter);
if (!customFooterContainer.isConnected) parentContainer.append(customFooterContainer);
// * Adding Event Listener on Next & Prev Button
nextButton.addEventListener("click", clickNextButton);
prevButton.addEventListener("click", clickPrevButton);
// * Mutation Observer Start
// Configuration Mutation Observer
const config = {
attributes: true,
attributeFilter: ["class"],
childList: true,
subtree: true,
};
// Callback Mutation Observer
const callback = function(mutationsList, observer) {
mutationsList.forEach(debounce((mutation) => {
const index = ghlSlides.indexOf(mutation.target);
if (index > 0 && !prevButton.isConnected) {
customFooter.prepend(prevButton);
customFooter.style = `justify-content: center !important`;
}
if (index === 0) {
prevButton.remove();
customFooter.style = `justify-content: center !important`;
}
if (index === ghlSlides.length - 1) {
nextIcon.className = data.customButtons.submitButtonIcon;
nextButton.innerHTML = data.customButtons.submitButtonText + nextIcon.outerHTML;
nextButton.addEventListener("click", clickSubmitButton);
} else {
nextIcon.className = data.customButtons.nextButtonIcon;
nextButton.innerHTML = data.customButtons.nextButtonText + nextIcon.outerHTML;
nextButton.addEventListener("click", clickNextButton);
}
}, 100), );
};
// Creating Mutation Observer
const observer = new MutationObserver(callback);
observer.observe(ghlSlidesContainer, config);
// * Listener Functions
// click next button
function clickNextButton(e) {
e.preventDefault();
document.querySelector("#_builder-form > div.ghl-footer > div > div.ghl-btn.ghl-footer-next", )?.click();
}
// click prev button
function clickPrevButton(e) {
e.preventDefault();
document.querySelector("#_builder-form > div.ghl-footer > div > div.ghl-btn.ghl-footer-back", )?.click();
}
// click submit button
function clickSubmitButton(e) {
e.preventDefault();
document.querySelector("#_builder-form > div.ghl-footer > div > div.ghl-btn.ghl-submit-btn", )?.click();
}
})();
</script>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-odd form-field-container" data-v-fd05e6d5=""><!---->
<div data-v-fd05e6d5="" class="form-builder--item"><!---->
<div id="customHTML_html_iovcfze2zat3213-hl-custom-code">
<script>
(function() {
const form = document.querySelector("#_builder-form");
const agreeRadios = [...form.querySelectorAll('input[type="radio"][value="Agree"]'), ];
let serial = 0;
agreeRadios.forEach((radio, index) => {
radio.addEventListener("change", function() {
if (this.checked) {
const nextAgreedTerms = agreeRadios[index + 1];
if (nextAgreedTerms) {
nextAgreedTerms.scrollIntoView({
behavior: "smooth"
});
setTimeout(() => window.scrollBy(0, -40), 500);
}
}
});
});
})();
</script>
</div>
</div><!---->
</div>
</div>
<div class="col-12" data-v-fd05e6d5="">
<div class="f-even form-field-container" data-v-fd05e6d5=""><!---->
<div data-v-fd05e6d5="" class="form-builder--item"><!---->
<div id="customHTML_html_iovcfze2zat3214-hl-custom-code">
<script>
(async () => {
const accessData = ["first_name", "last_name", "email", "phone", "primary_date_of_birth_mm-dd-yyyy", "do_you_use_tobacco_regularly", "what_is_your_gender", "address", "city", "state", "postal_code", "terms_and_conditions", ];
let submitted = false;
await wait(2000);
const nextButton = document.querySelector(".fc_custom-next-btn");
nextButton.addEventListener("click", async () => {
const obj = {
formId: "cnomRFiBYQhk72TjWbY4",
location_id: "ZEgBOYA0NimImViHQngi",
};
const inputs = document.querySelectorAll("input");
const termsCheckBox = document.querySelector("[data-q='terms_and_conditions']", );
inputs.forEach((input) => {
const key = input.getAttribute("data-q");
const value = input.value;
if (!value) return;
if (!accessData.includes(key)) return;
obj[key] = value;
});
if (obj["terms_and_conditions"] && !submitted) {
await wait(1000);
if (termsCheckBox.checked) canvasToFile(obj);
}
});
function wait(ms) {
return new Promise((resolve) => setTimeout(resolve, ms));
}
// Function to convert canvas to a Blob and then to a File
async function canvasToFile(obj) {
const canvas = document.querySelector(".signature-container canvas");
// Convert canvas to a Blob
canvas.toBlob(async function(blob) {
// Create a File from the Blob
const file = new File([blob], "signature.png", {
type: "image/png"
});
// For demonstration, logging the file object
// Example: Post FormData to a server
// You might need to adjust the URL and handle server-side receiving accordingly
const submitedData = await submitFormViaApi({
data: obj,
fileKey: "HB1gQTakDEAKKcwEMAZQ",
file,
});
submitted = true;
console.log({
submitedData
});
// END
}, "image/png");
}
async function submitFormViaApi({
data,
fileKey,
file
}) {
console.log({
data,
fileKey,
file
});
const formdata = new FormData();
formdata.append("formData", JSON.stringify(data));
formdata.append(fileKey, file);
const requestOptions = {
method: "POST",
body: formdata,
redirect: "follow",
};
try {
const response = await fetch("https://services.leadconnectorhq.com/forms/submit", requestOptions, );
const result = await response.json();
return result;
} catch (error) {
console.error(error);
return null;
}
}
// This function can be triggered by a button click or another event
})();
</script>
</div>
</div><!---->
</div>
</div><!--]-->
</div>
</div><!--]-->
</div><!---->
<div class="ghl-footer"
style="box-shadow:0 0 7px 0 rgba(50, 50, 50, 0.75);webkit-box-shadow:0 0 7px 0 rgba(50, 50, 50, 0.75);background-color:#007ce2FF;font-family:'Roboto';border-radius:0;font-size:14px;position:absolute;font-weight:500;height:50px;"
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$0 Healthcare Insurance - Find Out If You Qualify $0 Healthcare Insurance - Find Out If You Qualify $0 ACA/HEALTH COVERAGE WITHOUT HAVING TO SPEAK TO AN AGENT WELCOME - JUST A FEW QUESTIONS TO FINALIZE YOUR APPLICATION FOR $0 HEALTH INSURANCE: TIME: 2 MINUTES OR LESS First Name * Last Name * Email * Phone * Primary Date of Birth MM/DD/YYYY * What is your gender? * Male Female Where should we send your insurance cards? PO Box is not accepted. Physical address only. Address * City * State * Postal code * Moving right along, we just need a quick signature to continue: I hereby authorize Logan Holle to act as my authorized representative for health insurance matters, including but not limited to, enrolling myself and, if applicable, my household, in a Qualified Health Plan through the Federally Facilitated Marketplace. This consent encompasses the following authorizations for Logan Holle: 1. To access and manage any existing Marketplace applications; 2. To facilitate eligibility assessments and enrollment in Marketplace Qualified Health Plans or other related government programs (e.g., Medicaid, CHIP, advance tax credits); 3. To provide necessary ongoing support and enrollment assistance; 4. To handle inquiries from the Marketplace related to my application; 5. To switch my plan to a superior option if available or otherwise act as my agent of record, subject to my right to alter this authorization; 6. To acknowledge my income is below 100% of the federal poverty level and I agree to actively seek employment that pays at least the minimum wage. I affirm that Logan Holle is permitted to use my personally identifiable information (PII) solely for the purposes listed above, pledging to maintain the confidentiality and security of such information. I declare that all information provided for my eligibility and enrollment will be accurate to the best of my knowledge. I acknowledge that sharing additional personal or health information beyond what is required for application purposes is not obligatory. This consent is effective until revoked, which I may do at any time via email, text, or phone call to Logan Holle at the contact details provided below. Primary Writing Agent: Logan Holle National Producer Number: 18496827 Phone: +602-699-4545 Email: loganholleaca@gmail.com I agree to terms & conditions provided by the Nationwide Health Alliance. By providing my phone number, I agree to receive text messages from the business. Sign Below * Clear Next, we need to check your program eligibility: Primary Applicant's Social Security Number * This is required by Healthcare.gov to verify your identity. Tell us about your current coverage: IMPORTANT: If you are currently enrolled in a Medicare or Medicaid plan you will not qualify. However, if you recently lost coverage please continue with the application. Are you currently enrolled in Medicare OR Medicaid? * Yes No Just Lost Coverage We are here to help: Please provide the date you lost coverage: * Tell us about your current employment status: What is your employment status? * Employed Unemployed What is your Employer Name? * What is your Employer phone number? * Who do you say you're supporting on your tax forms? * * Myself * Myself + Spouse * Myself + Dependent(s) * Myself + Spouse + Dependent(s) * No elements found. Consider changing the search query. * List is empty. READ CLOSELY * You = 1 * Spouse = 1 * Dependents you claim on your taxes(Ie, children, parents you pay for their cost of living, adopted family members) = 1 each To qualify for $0 Health Coverage you must make below $1,822 per month. Please Select Your Monthly Income: * * $1,215 - $1,299 * $1,300 - $1,399 * $1,400 - $1,499 * $1,500 - $1,599 * $1,600 - $1,699 * $1,700 - $1,799 * $1,800 - $1,822 * No elements found. Consider changing the search query. * List is empty. To qualify for $0 Health Coverage you must make below $2,465 combined per month: What is your current monthly income? (Spouse NOT Included) * * $0 - $99 * $100 - $199 * $200 - $299 * $300 - $399 * $400 - $499 * $500 - $599 * $600 - $699 * $700 - $799 * $800 - $899 * $900 - $999 * $1,000 - $1,099 * $1,100 - $1,199 * $1,200 - $1,299 * $1,300 - $1,399 * $1,400 - $1,499 * $1,500 - $1,599 * $1,600 - $1,699 * $1,700 - $1,799 * $1,800 - $1,899 * $1,900 - $1,999 * $2,000 - $2,099 * $2,100 - $2,199 * $2,200 - $2,299 * $2,300 - $2,399 * $2,400 - $2,465 * No elements found. Consider changing the search query. * List is empty. What is your Spouses monthly income? * * S0 -$99 * $100 - $199 * $200 - $299 * $300 - $399 * $400 - $499 * $500 - $599 * $600 - $699 * $700 - $799 * $800 - $899 * $900 - $999 * $1,000 - $1,099 * $1,100 - $1,199 * $1,200 - $1,299 * $1,300 - $1,399 * $1,400 - $1,499 * $1,500 - $1,599 * $1,600 - $1,699 * $1,700 - $1,799 * $1,800 - $1,899 * $1,900 - $1,999 * $2,000 - $2,099 * $2,100 - $2,199 * $2,200 - $2,299 * $2,300 - $2,399 * $2,400 - $2,465 * No elements found. Consider changing the search query. * List is empty. Spouse's Employer Name Spouse's Employer Phone Number IMPORTANT: You and your spouse cannot make more than $2,465 per month combined. Please verify before continuing To be eligible for $0 Health Coverage, your income must be within the specified range, which varies based on your family size. What is your current monthly income? (Dependent(s) NOT included) * $ To be eligible for $0 Health Coverage, your income must be within the specified range, which varies based on your family size. What is your current monthly income? (Spouse & Dependent(s) NOT included) * $ What is your spouse's monthly income? (Sole Income Only) * $ You must complete the information below even if you are not wanting to enroll them in a plan. Spouse Legal First Name * Spouse Legal Last Name Spouse's Date of Birth MM-DD-YYYY * Spouse's Gender * Select your spouse gender * Male * Female * Other * No elements found. Consider changing the search query. * List is empty. Do you want us to enroll your spouse? * Yes No Next, we need to check program eligibility for your spouse: Spouse Social Security Number * This is required by Healthcare.gov to verify your spouses identity. Do you have Any Dependents? * Yes No You must complete the information below even if you are not wanting to enroll them in a plan. Dependent 1st Full Legal Name * Dependent 1st Gender * Select your first dependent gender * Male * Female * No elements found. Consider changing the search query. * List is empty. Dependent 1st Date of Birth MM-DD-YYYY * Relationship to dependent 1 * * Child (including adopted children) * Parent (including adoptive parents) * Stepparent * Stepchild * Grandparent * Grandchild * Brother or Sister (including half and step-siblings) * Uncle or Aunt * Nephew or Niece * Cousin * Adopted Child * Foster Child * Foster Parent * Son-in-law or Daughter-in-law * Brother-in-law or Sister-in-law * Mother-in-law or Father-in-law * Ward * Former Spouse * Sponsored Dependent * Dependent of a Minor Dependent * Ex-spouse * Guardian * Court Appointed Guardian * Collateral Dependnet * Life Partner * Annultant * Trustee * Other Relationship * Other Relative (including by marriage and adoption) * Parent's Domestic Partner * Child of Domestic Partner (including adopted children) * Unknown * No elements found. Consider changing the search query. * List is empty. Do you want to enroll dependent 1? * Yes No Next, we need to check program eligibility for your dependents: Dependent 1st Social Security Number * This is required by Healthcare.gov to verify your dependents identity. Do you have a 2nd Dependent? * Yes No You must complete the information below even if you are not wanting to enroll them in a plan. Dependent 2nd Full Legal Name * Dependent 2nd Gender * Enter your 2nd dependent gender * Male * Female * No elements found. Consider changing the search query. * List is empty. Dependent 2nd Date of Birth MM-DD-YYYY * Relationship To Dependent 2 * * Child (including adopted children) * Parent (including adoptive parents) * Stepparent * Stepchild * Grandparent * Grandchild * Brother or Sister (including half and step-siblings) * Uncle or Aunt * Nephew or Niece * Cousin * Adopted Child * Foster Child * Foster Parent * Son-in-law or Daughter-in-law * Brother-in-law or Sister-in-law * Mother-in-law or Father-in-law * Ward * Former Spouse * Sponsored Dependent * Dependent of a Minor Dependent * Ex-spouse * Guardian * Court Appointed Guardian * Collateral Dependent * Life Partner * Annultant * Trustee * Other Relationship * Other Relative (including by marriage and adoption) * Parent's Domestic Partner * Child of Domestic Partner (including adopted children) * Unknown * No elements found. Consider changing the search query. * List is empty. Do you want to enroll dependent 2? * Yes No Dependent 2nd Social Security Number * Do you have a 3rd Dependent? * Yes No You must complete the information below even if you are not wanting to enroll them in a plan. Dependent 3rd Full Legal Name * Dependent 3rd Gender * Enter your 3rd dependent's gender * Male * Female * No elements found. Consider changing the search query. * List is empty. Dependent 3rd Date of Birth MM-DD-YYYY * Relationship To Dependent 3 * * Child (including adopted children) * Parent (including adoptive parents) * Stepparent * Stepchild * Grandparent * Grandchild * Brother or Sister (including half and step-siblings) * Uncle or Aunt * Nephew or Niece * Cousin * Adopted Child * Foster Child * Foster Parent * Son-in-law or Daughter-in-law * Brother-in-law or Sister-in-law * Mother-in-law or Father-in-law * Ward * Former Spouse * Sponsored Dependent * Dependent of a Minor Dependent * Ex-spouse * Guardian * Court Appointed Guardian * Collateral Dependent * Life Partner * Annultant * Trustee * Other Relationship * Other Relative (including by marriage and adoption) * Parent's Domestic Partner * Child of Domestic Partner (including adopted children) * Unknown * No elements found. Consider changing the search query. * List is empty. Do you want to enroll dependent 3? * Yes No Dependent 3rd Social Security Number * Do you have a 4th Dependent? * Yes No You must complete the information below even if you are not wanting to enroll them in a plan. Dependent 4th Full Legal Name * Dependent 4th Gender * Select your 4th dependent gender * Male * Female * No elements found. Consider changing the search query. * List is empty. Dependent 4th Date of Birth MM-DD-YYYY * Relationship To Dependent 4 * * Child (including adopted children) * Parent (including adoptive parents) * Stepparent * Stepchild * Grandparent * Grandchild * Brother or Sister (including half and step-siblings) * Uncle or Aunt * Nephew or Niece * Cousin * Adopted Child * Foster Child * Foster Parent * Son-in-law or Daughter-in-law * Brother-in-law or Sister-in-law * Mother-in-law or Father-in-law * Ward * Former Spouse * Sponsored Dependent * Dependent of a Minor Dependent * Ex-spouse * Guardian * Court Appointed Guardian * Collateral Dependent * Life Partner * Annultant * Trustee * Other Relationship * Other Relative (including by marriage and adoption) * Parent's Domestic Partner * Child of Domestic Partner (including adopted children) * Unknown * No elements found. Consider changing the search query. * List is empty. Do you want to enroll dependent 4 * Yes No Dependent 4th Social Security Number * Do you have a 5th Dependent? * Yes No You must complete the information below even if you are not wanting to enroll them in a plan. Dependent 5 Full Legal Name * Dependent 5th Gender * Select your 5th dependent gender * Male * Female * No elements found. Consider changing the search query. * List is empty. Dependent 5th Date of Birth MM-DD-YYYY * Do you want to enroll dependent 5 * Yes No Dependent 5th Social Security Number * Do you have a doctor you would like to keep? * Yes No Doctor's Name Doctor's City Doctor's State You made it to the last page, please sign below to finalize your program submission: I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit. * Agree Disagree The Centers for Medicaid & Medicare Services (CMS) now requires two forms of consent from our clients. You have already completed the first form of consent. Please read the attestations and sign that you understand. Select whether you agree or disagree to adhere to Marketplace regulations. Each year we inform you that you must file your taxes, how eligibility works, and how tax credits are reconciled. Please note that we cannot enroll you without your consent. Disagreeing with any of the below attestations may hinder the ability to enroll in a plan. Please ask your agent if you need further explanation on any of the following. I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: • I must file a federal income tax return for the 2024 tax year. • If I’m married at the end of 2024 , I must file a joint income tax return with my spouse. I also expect that: • No one else will be able to claim me as a dependent on their 2024 federal income tax return. • I’ll claim a personal exemption deduction on my 2024 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit. If any of the above changes: • I understand that it may impact my ability to get the premium tax credit. • I also understand that when I file my 2024 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax. * Agree Disagree To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt-out at any time. * Agree Disagree If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. Either I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation. Or I don’t give the Marketplace permission to end Marketplace coverage in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay full cost for their Marketplace plan. * Agree Disagree I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household. * Agree Disagree I hereby affirm that I have thoroughly reviewed and understood the contents of this attestation. Consequently, I hereby authorize Logan Holle to act in the capacity of my broker, representing both myself and the members of my household, specifically for the purpose of enrolling in a qualified Health Plan through the Federally Facilitated Marketplace. Furthermore, I expressly consent to permit the aforementioned agent to access, view, and utilize my confidential information strictly for the purposes delineated herein. 1. Search for an existing Marketplace Plan; 2. Complete an application for eligibility and enrollment in a Marketplace Plan; 3. Provide ongoing maintenance and enrollment assistance; 4. Respond to inquiries from the Marketplace regarding my application. I hereby declare that the information I have provided is both accurate and truthful for the purposes of my Marketplace Health Insurance Application. I affirm that I have read and agreed to the terms and conditions set forth, and I understand that the agent specified earlier will securely store and utilize my Personally Identifiable Information (PII) solely for the purposes outlined above. By submitting this document, I also affirm compliance with the income eligibility criteria as indicated in the chart below, assert that I am not a recipient of Medicare, Medicaid, or Employer Coverage, and declare that I do not use tobacco products, thereby making me eligible for Zero Premium Health Coverage. I acknowledge that my consent is effective until such time as I withdraw it. Withdrawal of consent can be executed by sending an email to logan@nhacares.com. By submitting your mobile number, you agree to receive texts, calls, and automated messages from Logan Holle. To opt-out, reply "STOP". Authorization Date * Authorization Signature * Clear CONTINUE Next PROUD PARTNERSHIPS Discover the top carriers we represent for you! 🤝 HOW IT WORKS Eligibility for a complimentary health plan is based on household income. If your income falls within the blue bracket, you qualify. Don't wait, submit the form below and find out! Family Size 100% 150% 200% 400% 1 $14,580 $21,870 $29,160 $58,320 2 $19,720 $29,580 $39,440 $78,880 3 $24,860 $37,290 $49,720 $99,440 4 $30,000 $45,000 $60,000 $120,000 5 $35,140 $52,710 $70,280 $140,560 By using our services, you agree to the following terms: Representation: You grant the authorized agent, as mentioned in the attestation disclaimer, the authority to act on your behalf concerning health insurance matters, including enrollment, renewals, and related decisions. Accuracy: You confirm that all information provided is true and accurate. False or misleading information can lead to the termination of services. Revocation: Your consent remains in effect until you revoke it. You may revoke or modify your consent at any time. Limitation of Liability: The authorized agent and associated entities are not liable for any errors or omissions in the services provided or for any damages, including indirect or consequential damages. Privacy Policy: Data Collection: Our Agents collect Personally Identifiable Information (PII) solely for the purposes mentioned in our Comprehensive Attestation Agreement. Data Protection: We are committed to ensuring the privacy and safety of your PII. Your data will not be shared for any purposes other than those explicitly stated in our agreement. Income Attestation: We use your income information solely to determine eligibility for health insurance programs and potential subsidies. TCPA Disclaimer: By providing your phone number, you expressly consent to receive auto-dialed and/or pre-recorded telemarketing calls, text messages, and/or emails from the authorized agent mentioned in the attestation disclaimer at the phone number and email address you provided, including for marketing purposes. You understand that consent is not a condition of purchase. Message and data rates may apply. Copyrights 2024 - All Rights Reserved. Terms & Conditions Privacy Policy Monarch Agency Solutions is a licensed health insurance agency (License Number: XXXXXX)