GIG Intake Form
Complete this online intake form with the requested personal, household, insurance, income, payment, attachment, consent, and signature information. All fields are optional unless the source document clearly required them.
Applicant and Household Information
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Consumer SSN
Household Member 1 Name
Household Member 1 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Household Member 1 Sex
Household Member 1 SSN
Household Member 2 Name
Household Member 2 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Household Member 2 Sex
Household Member 2 SSN
Household Member 3 Name
Household Member 3 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Household Member 3 Sex
Household Member 3 SSN
Household Member 4 Name
Household Member 4 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Household Member 4 Sex
Household Member 4 SSN
Address and Medical Information
Street Address
Apt / Suite
City
County
State
ZIP Code
Doctor(s) / Primary Care Physician
Specialist(s)
Dentist
Optometrist
Current Medications
Insurance, Tobacco, and Income Information
Are you, or your spouse covered under another healthcare insurance plan?
*
Please Select
Yes
No
Do you or any household member applying for coverage currently use tobacco?
*
Please Select
Yes
No
Name of person 1
*
Company / Employer 1
Income Source 1
*
2026 Income 1
*
Name of person 2
Company / Employer 2
Income Source 2
2026 Income 2
Name of person 3
Company / Employer 3
Income Source 3
2026 Income 3
Estimated Total Household Income
*
Payment Information
Would you like to provide payment information for premium payments?
*
Please Select
Yes
No
Routing Number
Account Number
Account Holder Name
Attachments and Notes
Documents Attached / Brought to Appointment
Additional Notes
Consents and Signatures
Consent to use and retrieve information from data sources
I agree to have my information used and retrieved from data sources for this application...
Acknowledgment of truthful answers and additional information
I understand that I'm required to provide true answers and that I may be asked to provide additional information...
Consumer Signature (Disclosures)
Date (Disclosures)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Name (Disclosures)
ACA Consent - Item 1 Initials
ACA Consent - Item 2 Initials
ACA Consent - Item 3 Initials
ACA Consent - Item 4 Initials
ACA Consent - Item 5 Initials
ACA Consent - Item 6 Initials
ACA Consent - Item 7 Initials
Consumer Signature (ACA Consent)
Date (ACA Consent)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Name (ACA Consent)
Agent Name
Submit
Submit
Should be Empty: