SCHEDULE APPOINTMENT
SCHEDULE APPOINTMENT
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How many people are in your household?
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Do you expect your household income to be greater than $
in 2015?
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Plan Type:
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Individual & Family Plans
Child Only Plans - Ages 0 - 20
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First Name
Last Name
Phone
Email
State
City
Address
Comments
Relationship
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
FirstName
Relationship
Gender
DOB
Zip Code
County
Tobacco
Applicant
Self
M
F
*
*
Spouse
Relationship
Spouse
Domestic Partner
Life Partner
Same Sex Partner
M
F
*
*
Dependent
Relationship
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
Dependent
Relationship
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
Dependent
Relationship
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
Dependent
Relationship
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
Dependent
Relationship
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
+ Add Dependent
Medical Plan Type
Health Off Exchange
Health On Exchange
Short-Term, Up to 12 Months of Temporary Coverage
Payment Option:
Single Payment
Monthly Payment
Note:
Some insurance companies only offer a "Monthly Payment" option. You may not receive all available plans by selecting a single payment option.
Start Coverage On:
Last Day of Coverage:
Note:
Some insurance companies only offer a "Single Payment" option. You may not receive all available plans by selecting a monthly payment option.
Start Coverage On:
Coverage For Up To:
3 Months
6 Months
9 Months
12 Months
How many people are in your household?
1
2
3
4
5
6
7
8
9
10
You may qualify for a government subsidy under the Affordable Care Act.
Enter your estimated 2015 household income to see if you are eligible.
$
2015 Estimated Income
Requested Effective Date:
October
November
December
What is your current health plan premium? (optional): $
/month