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Candor Legacy
888.480.9183
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*
" indicates required fields
Step
1
of
11
9%
When would you like coverage?
*
IMMEDIATELY
WITHIN 2 MONTHS
NOT SURE
What benefits are most important to you?
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EMERGENCY CARE/ HOSPITALIZATION
PREVENTIVE CARE
DENTAL
VISION
TELEHEALTH
COV. FOR PRE EXISTING CONDITIONS
Are you currently enrolled in medicare part A or B?
*
YES
NO
UNSURE
What is your date of birth?
Date of Birth:
*
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Month, Day, Year
Have you used tobacco in the last 12 months?
*
YES
NO
Will you be including your spouse/children in the health plan?
*
YES
NO
What is your spouse date of birth?
Spouse Date of Birth:
*
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1951
1950
1949
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1942
1941
1940
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Month, Day, Year
What gender is your spouse?
*
FEMALE
MALE
Has your spouse used tobacco in the last 12 months?
*
Yes
No
How many children will be on your policy?
Select One
0
1
2
3
4
5
6
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9
10+
First Name:
*
Last Name:
*
Email:
*
A member of our Individual Health insurance team is available to assist you with any questions or concerns you may have regarding your health insurance needs. You will now be directed to our online enrollment portal to complete your enrollment.