Application for an Affordable Care Act Marketplace Health Plan

Please complete the information below to secure your application.

First-Name

Last-Name

Street-Address

Apartment

City, State

Zip-Code

Date of Birth

Phone Number

Email-Address

Name of Employer (use your name if self-employed)

Monthly Income

Type of Work

Work-Phone-Number

Field 13

Does everyone have the same permanent home address?

Do you have plan to file a federall income tax return for 2021

Are you and your spouse responsible for a child 18 or younger who lives on you, but isn't on your tax return?

Is anyone a full-time student aged 18-22?

Is anyone pregnant, or has anyone had a child in the last 60 days?

Are all of you U.S citizens?

Social-Security, VISA, or Green Card #

Are any of you currently incarcerated (detained or jailed)?

Are any of you an American Indian or Alaska Native?

Are any of you offered health coverage through your job, someone else's job, or COBRA?

Were any of you in foster care at 18 AND are currently 25 or younger?

Will you claim your dependent on your federal income tax return for 2021?

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

I AGREE

If anyone on this application enrolls in Medicaid, I'm giving the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

I AGREE

I know I must tell the program I'll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account online or by calling 1-800-318-2596. TTY users should call 1-855-889-4325. I know a change in my information could affect eligibility for member(s) of my household

I AGREE

I'm signing this application under penalty of perjury, which means I've provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

I AGREE

Spouse-First-Name

Spouse-Last-Name

Spouse-Date-of-Birth

Spouse Social-Security, VISA, or Green Card #

Spouse Employer

Spouse Monthly Income

Child 1 Full Name

Child 1 Date of Birth

Child 1 Social-Security, VISA, or Green Card #

Child 2 Full Name

Child 2 Date of Birth

Child 2 Social-Security, VISA, or Green Card #

Additional notes (if applicable)

FULL NAME (as signature)

Application for an Affordable Care Act Marketplace Health Plan

Please complete the information below to secure your application.

NameInsurance of (City)AddressEmailOffice or Text: (Number)Privacy Policy

Name
Insurance of (City)
Address
Email
Office or Text: (Number)
Privacy Policy