Health Insurance Application – Fill Out and Use This PDF

The contact person for your application is 1 adult in the household.

Print in capital letters using black or dark blue ink only.

Enter 1. First name, Middle name, Last name and Suffix; 2. Home address (Leave blank if you don't have one.); 3. Home address 2; 4. City; 5. State; 6. ZIP code; 7. County.

Enter 8. Mailing address (if different from home address); 9. Mailing address 2; 10. City; 11. State; 12. ZIP code; 13. County.

Enter 14. Phone number and 15. Second phone number.

16. Do you want to get information about this application by email? Yes or No. Enter your Email address.

17. Preferred language: Written and Spoken.

Complete the Step 2 pages for each person in your household, even if the person has health coverage already. Start with yourself, then add other adults and children.

If you have more than 2 people in your household, you'll need to make a copy of the pages and attach them.

You don't need to provide immigration status or SSNs for household members who don't need health coverage.

You don't need to file taxes to get health coverage.

Include these people even if they aren't applying for health coverage for themselves: any spouse; any child under age 21 they live with, including stepchildren; any other person on the same federal income tax return (including any children over age 21 who are claimed on a parent's tax return).

Include these people even if they aren't applying for health coverage themselves: any parent (or stepparent) they live with; any sibling they live with; any child they live with, including stepchildren; any spouse they live with; any other person on the same federal income tax return.

You can still apply for coverage even if you don't file a federal income tax return. If yes, answer items a through c. If no, skip to item c.

a. Will you file jointly with a spouse? If yes, write name of spouse. b. Will you claim any dependents on your tax return? If yes, list name(s) of dependents. c. Will you be claimed as a dependent on someone's tax return? If yes, list the name of the tax filer: How are you related to the tax filer?

If you're currently employed, start with item 20. Not employed: Skip to item 30. Self-employed: Skip to item 29.

Complete this question if your income changes during the year, like if you only work at a job for part of the year or get a benefit for certain months. If you don't expect changes to your monthly income, skip to the next person.

Complete this appendix if you or a household member are American Indian or Alaska Native and are applying for coverage. Submit this with your “Application for Health Coverage & Help Paying Costs.”

Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, like a parent or spouse, even if they don't accept the coverage. Check no if the only coverage offered is COBRA.

You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job, even if they don't accept the coverage. You also don't need to answer these questions if the only coverage someone is offered is COBRA.

If you're an authorized representative, you may sign here as long as PERSON 1 signed Appendix C.

I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

I know that I must tell the Health Insurance Marketplace® within 30 days if anything changes (and is different than) what I wrote on this application.

If you're signing this application outside of Open Enrollment (November 1-January 15), make sure you review Appendix D (“Questions about life changes”).

For certified application counselors, navigators, agents, and brokers only: complete this section if you're a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

If you're a legally appointed representative for someone on this application, submit proof with the application.

Mail your signed application to: Health Insurance Marketplace, Dept. of Health and Human Services, 465 Industrial Blvd., London, KY 40750-0001.