Covered California Eligibility Questionnaire

Covered California Eligibility Questionnaire

Please note that this form is not an application for enrollment. Its purpose is to verify your eligibility for Covered CA. After reviewing this form, an agent will contact you to further discuss your eligibility and provide guidance.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for applying?

Loss of coverageGained Legal StatusMedi-CalPregnant (AIM Program)Moved
Does your employer offer you healthcare? (Applies to Employers with 50+ employees)

YesNoNot Applicable
Are you Native American?

YesNo
Household Size (Include only the tax filer and any spouse or dependents even if they are not applying for insurance).
How many need coverage?

	Age of People Needing Coverage
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6

Household Income (Estimated combined income for all family members claimed on taxes).
Eligibility: You must be able to estimate at least the minimum qualifying annual household income to be eligible for a government subsidy.

You can use income from these sources: cash, wages, salary, tips, commissions, bonuses, severance pay, self-employment from freelance, consulting, or contract work, unemployment compensation, pensions from former employers, Social Security, capital gains investments, like interest on savings or dividends from stocks or mutual funds, retirement, including withdrawals from most 401(k) and IRA accounts, alimony, gambling, prizes, awards, taxable scholarships, and grants.
Income Source:

Federal W-2 WagesSelf-employmentUnemployment CompensationSocial SecuritySocial Security Disability (SSDI)Retirement or PensionInvestment IncomeAlimony
Upon filing your 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the income stated on your tax return with the income provided in your application. Should your tax return show a lower income than the amount stated in your application, you may qualify for an additional premium tax credit. Conversely, if your tax return shows a higher income than stated in your application, you may be required to pay additional federal income tax. I am not qualified to provide legal or tax advice. For guidance specific to your circumstances, please consult with your attorney, accountant, and/or tax advisor. I reserve the right to decline any service that may be considered unlawful, without incurring any liability.
Proof of income

Cancelof
Additional information that we should know:
Appointment Request
By clicking "Submit," I authorize HRBC Insurance and its agents to contact me regarding my Covered CA eligibility for health insurance coverage.
Should be Empty: