Applicant Information for ACA Open Enrollment Step 1 of 2 50% Name* First Middle Last Email* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date of Birth SSNGenderFemaleMaleUse Tobacco?YesNoEmployerIs group health insurance offered at your place of employment?YesNoNot 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?YesNoAre there any other members in the household, including grandparents, roommates, etc, who will not be on the policy?YesNoPlease 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 incomeHow do you file?SingleMarriedMarried, filing at single rateNumber of dependents claimed on your tax returnAny additional household income (for dependents or household members even if they are not included on the application coverage)?YesNoList the additional incomes and their sources
