Confirm your coverage details
Tell us about yourself
Enter your first name.
Enter your last name.
Enter your name as it appears on your ID.
Enter a valid date of birth.
Your contact information
Enter a valid email address.
Required on the application. The carrier sends your policy documents here.
Enter a valid phone number.
Required on the application.
Where do you live?
Enter your street address.
Use your permanent home address, not a PO box.
Enter a city name without numbers.
Enter a 5-digit ZIP code.
Who else is on this application?
Include everyone on your tax return, even if they do not need coverage.
Expected household income
Enter your expected annual income.
Everyone on your tax return. This determines your premium tax credit.
An affordable employer offer can make you ineligible for a tax credit. “Affordable” is defined as a plan meeting Minimum Value, with premiums totaling less than 10.22% of your annual income.
Check your details
Application received
A licensed agent will contact you to finalize your enrollment. Keep an eye on your email for plan documents from the carrier.