Have you had a major life change?
Report any event that may affect your health coverage here.
Family Change
Please Select
Birth or Adoption
Marriage
Divorce or Separation
Death
Date of the event
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Names involved
Does this affect anyone else's coverage?
Yes
No
Upload document (certificate, etc.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional comments
Address Change
Please Select
Move within the same state
Move to another state
Zip code change
New 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
Move-in date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does anyone else's move with you?
Yes
No
Is your current coverage still available?
Yes
No
Employment & Income
Please Select
Lost job
Started a new job
Income change
Employment status change
Date of change
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employer name (if applicable)
Did your income increase or decrease?
Increase
Decrease
Insurance Coverage
Please Select
Lost previous coverage
Gained new coverage
CHIP / Medicaid CHIP eligibility chance
Date of change
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of previous coverage
Who is affected?
Upload termination or confirmation letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Legal or Student Status
Legal or Student Status Change
Please Select
Citizenship or immigration change
Start or end out-of-state studies
Date of change
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of change
Upload document (visa, enrollment, etc.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Does this affect your current coverage?
Yes
No
Other Change
Describe the change
Date of event
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who is affected?
Upload document (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Continue
Continue
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