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Pre-Qualification
Medical Sharing Ministry Plans

* Indicates required questions
Name *
First
Last
Email
Phone # *
Zip/Postal Code *
-
Country *
Please select your advisor *
Are you currently receiving an Advanced Premium Tax Credit (APTC) from the Health Insurance Marketplace (HIM) to help pay your health insurance premiums? *
Do you currently have a High Deductible Health Plan (HDHP) that allows you to use tax-free money for your health care expenses? *
Have you been diagnosed with cancer or any other critical illness in the past 5 years? *
Are you currently pregnant or taking immediate steps to become pregnant? *
Do you have any surgeries scheduled currently or have you been advised to have surgery by a medical professional? *
Are you willing to change providers (i.e. Primary Care Physician, Specialists, Hospitals) to save thousands of dollars per year in medical care premiums? *
Current Health Insurance Carrier *
Current monthly premium
Current plan level
Person 1 - Age *
Person 1 - Sex *
Person 1 - Uses Tobacco *
Person 2 - Age
Person 2 - Sex
Person 2 - Uses Tobacco
Person 3 - Age
Person 3 - Sex
Person 3 - Uses Tobacco
Person 4 - Age
Person 4 - Sex
Person 4 - Uses Tobacco
Person 5 - Age
Person 5 - Sex
Person 5 - Uses Tobacco
Person 6 - Age
Person 6 - Sex
Person 6 - Uses Tobacco
Person 7 - Age
Person 7 - Sex
Person 7 - Uses Tobacco
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