Form Submission is restrictedForm is successfully submitted. Thank you!Health Insurance QuestionnaireStep1Step2Step2DateFirst NameLast NameHome AddressHome Zip Code*CountyCell PhoneHome PhoneWill you use text messaging?YesEmailMarital StatusSingleMarriedDivorcedWidowedDomestic PartnerSpouse / Domestic Partner NameCurrent Insurance CompanyPlan NumberPlan CostWhen do you want coverage to start?Did you lose coverage within the last 60 days or anticipating losing coverage in the future?YesDate of Loss of CoverageAre you currently on a plan that offers a subsidy/tax credit (is your plan discounted?)YesNoEstimated household income for 2023 or the best estimate for total current monthly incomeAre you offered health insurance through a job?YesNoCurrent employer benefit manager's phone numberUpload Plan Information Upload% Completed0 Do you or anyone you want on your plan have Medicaid or qualify for Medicaid?YesNoWhat type of plan are you looking for?IndividualIndividual & ChildIndividual & SpouseFamilyWho do you want covered on your plan?NameSexMaleFemaleDate of BirthZip or CountyTobacco UserYesNo Please List your MedicationsMedication NameDosageFrequency of Usage Submit
