Complete any required and/or optional form
fields.
Click the "I accept" button to submit the form.
Click the "Do not accept" button to cancel sending the form.
Click the "Reset" button to clear all form fields.
Form Field Descriptions
Zip Code: (Required)
Enter a valid Oklahoma zip code. (Example: 73001 or
73001-1234)
Date of birth for the Applicant: (Required)
Type in the applicant's date of birth. (Example: 01/07/1970)
Gender for Applicant: (Required)
Click on the male or female box to insert a checkmark which will indicate
the gender.
Tobacco User for Applicant: (Optional)
Click on the tobacco box to insert a checkmark which will indicate YES,
the applicant has used tobacco in the past 12 months or the applicant is a
current tobacco user.
Maternity for Applicant: (Optional)
Click on the maternity box to insert a checkmark which will indicate YES.
Maternity coverage is available to females age 19 or more.
Number of dependents under age 19: (Required)
Click on the box to the left of the number to insert a checkmark that
indicates the number of dependents.
Additional HELP for spouse information
Date of Birth for Spouse: (Required)
Type in the spouse's date of birth. (Example: 01/07/1970)
Gender for Spouse: (Required)
Click on the male or female box to insert a checkmark which will indicate
the gender.
Tobacco User for Spouse: (Optional)
Click on the tobacco box to insert a checkmark which will indicate YES,
the applicant has used tobacco in the past 12 months or the applicant is a
current tobacco user.
Maternity for Spouse: (Optional)
Click on the maternity box in to insert a checkmark which will indicate
YES. Maternity coverage is available to females age 19 or more.
