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1Applicant

2Spouse

3Dependents

4Household

5Select Plan

Do you need health coverage?

With Trusty Oaks, you can apply for yourself or any household member.

Age *

Sex *

Male
Female

Select any that apply

Tobacco user
Eligible for coverage through a job
Eligible for coverage through Medicaid, CHIP, or Medicare

Do you have a spouse? *

Yes
No

Age of Spouse *

Sex *

Male
Female

Select any that apply to your Spouse

Tobacco user
Eligible for coverage through a job
Eligible for coverage through Medicaid, CHIP, or Medicare

Do you have any dependents under your care? *

Yes
No

Dependents' Profile

Age *

Sex *

Male
Female

Select any that apply

Tobacco user
Eligible for coverage through a job
Eligible for coverage through Medicaid, CHIP, or Medicare

to Dependents' your

Your household information

How many individuals are included in your tax household? *

Provide an estimate of your 2026 household income prior to taxes *

Name *

First

Last

Phone *

Email *

Zipcode *

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