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ACA Open Enrollment
Applicant Information for ACA Open Enrollment
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1
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50%
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Use Tobacco?
Yes
No
Employer
Is group health insurance offered at your place of employment?
Yes
No
Not Sure
Please add names of additional dependents and date of birth here:
You may be eligible for a tax subsidy. Are you interested in determining your eligibility?
Yes
No
Are there any other members in the household, including grandparents, roommates, etc, who will not be on the policy?
Yes
No
Please enter the names and relationships of other members of your household who will not be on the policy.
Applicant's estimated annual gross income:
Spouse's estimated annual gross income
How do you file?
Single
Married
Married, filing at single rate
Number of dependents claimed on your tax return
Any additional household income (for dependents or household members even if they are not included on the application coverage)?
Yes
No
List the additional incomes and their sources
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