(WEB) Qualified Health Coverage

1

Are you looking for Individual or Family Coverage?

Individual

Family

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Zip Code* This field is required.

4

What is your estimated household income for this year? * This field is required.

5

How many household members do you claim on your taxes?

6

Ages of everyone that needs coverage

7

9

Name* This field is required.

First Name

Last Name

10

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

11

Email* This field is required.

example@example.com

12

Date of Birth* This field is required.

Date

13

Occupation or Line of Work

14

Are you married?

YESNO

15

Spouse Name

First Name

Last Name

16

Spouse Date of Birth

Date

17

Do you have any dependents?

YESNO

18

First Dependent Name

First Name

Last Name

19

First Dependent Date of Birth

Date

20

Do You have another dependent?

YESNO

21

Second Dependent Name

First Name

Last Name

22

Second Dependent Date of Birth

Date

23

Do You have another dependent?

YESNO

24

Third Dependent Name

First Name

Last Name

25

Third Dependent Date of Birth

Date

26

Do You have another dependent?

YESNO

27

Fourth Dependent Name

First Name

Last Name

28

Fourth Dependent Date of Birth

Date

29

Do You have another dependent?

YESNO

30

Fifth Dependent Name

First Name

Last Name

31

Fifth Dependent Date of Birth

Date

32

Do You have another dependent?

YESNO

33

Sixth Dependent Name

First Name

Last Name

34

Sixth Dependent Date of Birth

Date

35

Do You have another dependent?

YESNO

36

Seventh Dependent Name

First Name

Last Name

37

Seventh Dependent Date of Birth

Date

38

Do You have another dependent?

YESNO

39

Eighth Dependent Name

First Name

Last Name

40

Eighth Dependent Date of Birth

Date

41

Do You have another dependent?

YESNO

42

Ninth Dependent Name

First Name

Last Name

43

Ninth Dependent Date of Birth

Date

44

Do You have another dependent?

YESNO

45

Tenth Dependent Name

First Name

Last Name

46

Tenth Dependent Date of Birth

Date

47

Are you eligible for health coverage from a job (including COBRA) or someone else’s job?* This field is required.

YESNO

48

Are you an American Indian or Alaska Native?* This field is required.

YESNO

49

Does anyone applying for coverage have a physical disability or mental health condition that limits their ability to work, attend school, or take care of their daily needs?* This field is required.

YESNO

50

Does anyone applying for coverage need help with daily activities (like dressing or using the bathroom) or lives in a medical facility or nursing home?* This field is required.

YESNO

51

SignatureYou're finished!! By submitting this form you are confirming that you authorize America First to submit your application for health insurance. Please be on the lookout for email confirmations of your plan. You can reach us at 877.999.5469 should you have any questions. Thank you for your time and welcome to the family!

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