Coverage Start Date            Date of Birth *   Have you used any form of tobacco in the past 12 months?  Yes No Gender  Male Female Residence Zip Code   * Include a household discount? select Select One Yes No   *Applies only to approved states    Get Quote Please Wait... In the following states only non-tobacco rates apply during open enrollment and guaranteed issue periods: AR, CO, IA, IL, KY ,LA, MD, MI, NC, ND, NJ, OH, PA, TN, UT, VA, WI.