Do you have insurance through your employer, Medicare, Medicaid, or VA? *
First Name *
Last Name *
Street Address *
City *
State *
Postal code *
Gender * MaleFemale
Phone *
Email
Main Applicant Birth Date (D.O.B.) *
Social Security - Main ACA Applicant
Are you married? * YesNo
Spouse Name *
Spouse Date of Birth *
Social Security - Only if Applying
Are you filing taxes jointly with your spouse? YesNo
If you select No, you will not be eligible for coverage.
Do They Need Coverage? YesNo
Do you claim any dependents? * YesNo
Full Name *
Relationship to Applicant*
Relationship to Spouse*
Date Of Birth *
Add a dependent YesNo
Relationship to Dependents*
Do you plan to file a tax return for 2024? YesNo
Are you an American Indian or Alaska Native? YesNo
If you select Yes, you will not be eligible for coverage.
Are you a US citizen or US national? YesNo
Permanent Resident Card ('Green Card', l-551)Temporary l-551 Stamp (on passport or l-94, l-94A)Employment Authrization Card (EAS, l-766)Unexpired foreign passport
How many people need coverage? *
Please Be Accurate - Income Will Be Verified By Healthcare.gov
Do you currently get any income? YesNo
Name of Employer
Expected Monthly Income
Does your spouse currently get any income? YesNo
Expected Household Income Per Year
Please sign below attesting that you have reviewed and confirm the accuracy of your application information * [signature* signature-1000]
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