Health Marketplace Form 2026

Primary Applicant Information
Select individual(s) for Medical Coverage
Full Name

First NameLast Name
Date of Birth

MonthDayYear
e.g. MM-DD-YYYY
Social Security
e.g. 000-00-0000
Please provide your current living address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your current living address? If NO, please provide your mailing address.
Please provide your current mailing address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Select your current employment status.
Provide your current tax filing status
Are you a citizen of the United States?
If you are NOT a citizen of the United States, please indicate your current immigration status.
Provide your annual income.
Do you have any dependents?

If YES, provide list the number of dependents and their relationship to you.
Do you intend to file your taxes ?
Smoke
Please provide proof of identity

e.g. Driver License, Passport, State ID, Visa or other.
Cancelof
Please provide proof of income.

e.g. Recent pay stubs, W-2 Form, 1099 Form or Tax Return.
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Preferred Language
Please fill out the following if applicable.

(Spousal Information)
Full Name

First NameLast Name
Date of Birth

MonthDayYear
e.g. MM-DD-YYYY
Social Security
e.g. 000-00-0000
Do you share the same mailing address as your spouse? If NO, please fill out the next question.
Provide your current mailing address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Select your current job status.
Are you a citizen of the United States?
If you are NOT a citizen of the United States, please indicate your current immigration status.
Smoke
Provide your annual income.

Provide all Household Members

Rows	Full Name	DoB	SS	Are you applying?
1
2
3
4
5
6

Please provide proof of identity.

e.g. Driver License, Passport, State ID, Visa or other.
Cancelof
Upload your spouse's Driver's license, Passport, or any other evidence that confirms your citizens

Cancelof
Please provide proof of income.

e.g. Recent pay stubs, W-2 Form, 1099 Form Tax Return.
Cancelof
Upload your spouse's paystub or taxes

Cancelof
How you hear about us

Other
How did you hear about us?
If you were referred by a friend or family member, please provide their name.
Signature
Primary Care Physician (PCP)
This field is optional.
Additional Information That May Help Us Assist You
Please provide any additional comments, questions, or details relevant to your case or request.
Select your current job status.
Should be Empty:

Primary Applicant Information

Please fill out the following if applicable.