ACA Intake

Marketplace Intake Form
Primary Contact
Name*

First NameLast Name
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Calculated Age
MaleFemale
Social Security Number*
Tax Filing Status:*

Married filing jointlyMarried filing separatelySingleHead of household
Marital Status:*

MarriedSingle/Divorced
Enrolling in Marketplace insurance?*

YesNo
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Type*
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type
Tobacco?*

YesNo
US Citizen?*

YesNo
How would you like to receive updates from the Marketplace?*

MailEmailText
Do you currently have health insurance?*

YesNo
What insurance are you currently enrolled in?
Is anyone in your household offered insurance through a job?

YesNo
Today's date

MonthDayYear
Date
ADDITIONAL HOUSEHOLD MEMBERS: Include everyone that files taxes together, even if not applying for coverage. Add additional rows as needed.
GROSS HOUSEHOLD INCOME: Include everyone that files taxes together, even if not applying for coverage. Include all sources of income and add additional rows as needed.*
HOUSEHOLD DEDUCTIONS NOT DEDUCTED FROM INCOME*
Should be Empty:

Marketplace Intake Form