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Subscriber Information

Do you currently have coverage?

Do you have access to coverage through your employer or through a spouse?

Subscriber Full Name:

Date of Birth:

Street Address:

City:

State:

Zip Code:

County:

Phone Number (with area code):

Email Address:

Are you a United States citizen?

Do you use tobacco products?

Gender:

How many family members are seeking coverage?

Please list the name, date of birth and gender of each ADDITIONAL member seeking coverage:

Do you plan to file a tax return for 2021?

Do you plan to file a joint tax return?

Do you plan to claim any dependents on your tax return?

Are you claiming any dependents that are NOT enrolling in coverage?

If you would like to see if you qualify for financial assistance (APTC), please enter your estimated annual household income for 2021.

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