ACA PLANS

Contact Info

Person 1

Person 2

Coverage

Agreement

Step 1: Tell us about yourself

We need 1 adult in the household to be the contact person for your application.

First Name *

Middle Name

Last Name *

Suffix

Phone Number *

Second Phone Number

Preferred Written Language

Preferred Spoken Language

Home Address

Street Address

Address Line 2

City

State

ZIP Code

County

Mailing Address (if different from home)

Mailing Street Address

City

State

ZIP Code

Receive info by email?

Yes No

Email Address

Step 5: Your Agreement & Signature

Please read and agree to the terms below, then sign to submit your application.

By signing this application, you agree that all information provided is true to the best of your knowledge. You understand that intentionally providing false information is subject to federal penalties. You agree to report any changes to the Health Insurance Marketplace® within 30 days. You acknowledge that under federal law, discrimination based on race, color, national origin, sex, age, or disability is not permitted.

Do you agree to allow the Marketplace to use income data for the next 5 years?

Yes No

Is anyone on this application currently incarcerated?

Yes No

I have read and agree to the terms above. I am signing this application under penalty of perjury.

Signature

Draw your signature below *

Sign above using mouse or touch

Date Signed *

✓

Application Submitted

Thank you. Your application has been sent successfully. You should receive a confirmation email shortly, and an Eligibility Notice will follow within 1–2 weeks.

Questions? Call the Marketplace Call Center at 1-800-318-2596.

Application for Health Coverage& Help Paying Costs

Application Submitted

Application for Health Coverage
& Help Paying Costs