Question	Answer
Form Name	Health Insurance Application
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	insurance application, health insurance form, health insurance application form, medical insurance application form

		Who can use this	• Use this application to apply for anyone in your household.
		application?	• Apply even if you, your spouse, or your child already have health coverage.
			You could be eligible for free or lower-cost coverage.
			• If you’re single, you may be able to use a short form. Visit HealthCare.gov.
			• Households that include eligible immigrants can apply. You can apply for
			your child even if you aren’t eligible for coverage. Applying won’t affect your
			immigration status or chances of becoming a permanent resident or citizen.
			• If someone is helping you fill out this application, you may need to complete
			Appendix C.

		What you may	• Social Security Numbers (SSNs) (or document numbers for any eligible
		What you may
		need to apply	immigrants who need coverage).
		need to apply	• Employer and income information for everyone in your household (like from pay

			stubs, W-2 forms, or wage and tax statements).
			• Policy numbers for any current health insurance.
			• Information about any job-related health insurance available to your household.

		Why do we ask for	We ask about income and other information to let you know what coverage
		this information?	you qualify for and if you can get any help paying for it. We’ll keep all the
		this information?	information you provide private and secure, as required by law. To view the

			Privacy Act Statement, visit HealthCare.gov or see instructions.

16. Do you want to get information about this application by email?				Yes No

Email address:

17. Preferred language: Written				Spoken

a. Will you file jointly with a spouse?				Yes	No
	If yes, write name of spouse:

b. Will you claim any dependents on your tax return?				Yes	No

	If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone’s tax return?				Yes	No
	If yes, list the name of the tax filer:		How are you related to the tax filer?


8. Are you pregnant?		Yes No a. If yes, how many babies are expected during this pregnancy?
8. Are you pregnant?

10. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing,
dressing, daily chores, etc.), a special health care need, or live in a medical facility or nursing home?	Yes	No
11. Are you a U.S. citizen or U.S. national?	Yes	No

16. Are you a full-time student?			Yes No	17. Were you in foster care at age 18 or older?			Yes No
Optional:	18.	If Hispanic/Latino, ethnicity:	Mexican	Mexican American Chicano/a	Puerto Rican	Cuban	Other
(Fill in all that	19.	Race: White Black or African American American Indian or Alaska Native Filipino				Japanese	Korean Asian Indian Chinese
apply.)	Vietnamese Other Asian		Native Hawaiian Guamanian or Chamorro		Samoan Other Pacific Islander Other
	Vietnamese Other Asian		Native Hawaiian Guamanian or Chamorro		Samoan Other Pacific Islander Other

Employed: If you’re currently employed, tell us	Not employed:	Self-employed:
about your income. Start with item 20.	Skip to item 30.	Skip to item 29.

Unemployment		Alimony received (Note: Only for divorces finalized before 1/1/2019.)
$	How often?	$	How often?
Pension		Net farming/fishing
$	How often?	$	How often?
Social Security		Net rental/royalty
$	How often?	$	How often?
Retirement accounts		Other income, type:
$	How often?	$	How often?

Alimony paid (Note: Only for divorces finalized before 1/1/2019.)			Other deductions, type:
$	How often?	$		How often?
Student loan interest
$
$	How often?

Step 2: PERSON 2	Note: If this person doesn’t need health coverage, just answer questions 1–10 on this
	page. Make a copy of pages 4–5 if there are more than 2 people in your household.

$		$		Fill in if you think your income will be hard to predict.

Immigration document type:	Status type (optional):	Write PERSON 2’s name as it appears on their immigration document.

a. Type of work:
b. How much net
	income (profits once business expenses are paid) will PERSON 2 get from this	$

self-employment this month? See instructions.
self-employment this month? See instructions.

$		$		Fill in if you think your income will be hard to predict.

a. Will PERSON 2 file jointly with a spouse?					Yes	No
	If yes, write name of spouse:

b. Will PERSON 2 claim any dependents on his or her tax return?					Yes	No
	If yes, list name(s) of dependents:

c. Will PERSON 2 be claimed as a dependent on someone’s tax return?					Yes	No
	If yes, list the name of the tax filer:		How is PERSON 2 related to the tax filer?


9. Is PERSON 2 pregnant?		Yes		No a. If yes, how many babies are expected during this pregnancy?
9. Is PERSON 2 pregnant?		Yes

11. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities
(like bathing, dressing, daily chores, etc.), a special health care need, or live in a medical facility or nursing home?	Yes	No
12. Is PERSON 2 a U.S. citizen or U.S. national?	Yes	No

Step 2: PERSON 2	Tell us about any income PERSON 2 gets. Complete this page even if PERSON 2 doesn’t
	need health coverage.

Employed: If PERSON 2 is currently employed,	Not employed:	Self-employed:
tell us about his/her income. Start with item 22.	Skip to item 32.	Skip to item 31.

past 90 days? (Select yes only if someone was found not eligible for this coverage by your state, not by the Marketplace.)		Yes	No

Who?	Date:
Or, was anyone on this application found not eligible for Medicaid or CHIP due to their immigration status in the last 5 years?		Yes	No
Who?
Did anyone on this application apply for coverage during the Marketplace Open Enrollment Period or after a qualifying life event? ....		Yes	No
Who?

YES. Continue and then complete Appendix A.	NO.
If yes, is this a state employee benefit plan?	Yes	No
Is anyone listed on the application offered an individual coverage Health Reimbursement Arrangement (HRA)
or a Qualified Small Employer HRA (QSEHRA)?	Yes	No

Type of coverage:
Employer insurance COBRA Medicaid CHIP Medicare TRICARE	VA health care program Peace Corps Other
If it’s employer insurance: (You’ll also need to complete Appendix A.)
Name of health insurance company	Policy/ID number

Name of health insurance company			Policy/ID number


Is this a limited-benefit plan, like a school accident policy?			Yes No
Name of person enrolled in health coverage

2. Is anyone applying for health insurance on this application incarcerated (detained or jailed)?	Yes No
If yes, tell us the person’s name. The name of the incarcerated person is:

Health Insurance Application – Fill Out and Use This PDF

Health Insurance Application PDF Details