ACA Open Enrollment

Name*
First Middle Last
Email*
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
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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