Individual Health Individual Health Taking care of your own health can be an overwhelming task. Let us help get you the coverage you need. Individual Health Survey * required field Name Date of Birth Tobacco User Primary:* NoYes Spouse: NoYes Dependent: NoYes Dependent: NoYes Dependent: NoYes Dependent: NoYes Contact Email* Contact Phone* Zip Code* Current Carrier Current Deductible Current Plan Type Currently Monthly Premium: Please List in Order of Most Importance: (1=Most Important 2=Less important 3=Least Important) Low Monthly Premium Low Deductible Office Visit Co-Pays Available Please Indicate If Your Dr. is in the Aurora Network: NoYes
