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Required fields are marked with a red asterisk. *

Applicant's birth date * (mm/dd/yyyy)

Date coverage starts

Your coverage will begin the day after we receive your application, unless you choose a later date.

I want my coverage to begin on *

Minnesota Resident *

Are you a resident of the state of Minnesota?

Yes No

Substance abuse coverage

Coverage for substance abuse is included in the contract. You may choose to delete substance abuse coverage. Your premium will be slightly reduced if you delete substance abuse coverage.

If you have questions about substance abuse coverage, you can find more information in our help center.

Check this box to EXCLUDE substance abuse coverage

Tobacco use *

Have you used tobacco and/or smokeless tobacco during the past 24 months?

Yes No

NOTE: Tobacco-free rates are available only to persons who have not used tobacco and/or smokeless tobacco in the preceding 24 months.