Marketplace Intake Form
Primary Contact
Name
*
First Name
Last Name
Email
example@example.com
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Calculated Age
Male
Female
Social Security Number
*
Tax Filing Status:
*
Married filing jointly
Married filing separately
Single
Head of household
Marital Status:
*
Married
Single/Divorced
Enrolling in Marketplace insurance?
*
Yes
No
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address if different
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type
*
Please Select
Home
Mobile
Other
Additional Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type
Please Select
Tobacco?
*
Yes
No
US Citizen?
*
Yes
No
How would you like to receive updates from the Marketplace?
*
Mail
Email
Text
Do you currently have health insurance?
*
Yes
No
What insurance are you currently enrolled in?
Is anyone in your household offered insurance through a job?
Yes
No
Today's date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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
*
Submit
Should be Empty: