Marketplace Questions General InformationName *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail Address *Phone *Which county do you live in? (Not country) *Gender (Assigned at Birth) *MaleFemaleDate of Birth *Marital Status *SingleMarriedWidowedDomestic PartnershipSpouse's Name *Spouse's Date of Birth *Income InformationTax Filing Status *SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdDo you claim any dependents? *YesNoList the name and date of birth for EACH dependent *What do you expect your GROSS income to be in 2025? *If you file jointly, please enter your Joint income even if only one of you is looking for coverage.What do you expect your GROSS income to be in 2026? *If you file jointly, please enter your Joint income even if only one of you is looking for coverage.Current Health InsuranceHow are you currently insured? *My EmployerMy Spouse's EmployerThe Marketplace/State ExchangeRetiree PlanCOBRAFederal BenefitsMedicareI'm Not InsuredDo you have a Health Savings Account (HSA)? *YesNoTell me about why you are looking for coverage and when you would need it to start. *Prescriptions and DoctorsHow many times do you see doctors during the year? *0-4 times per year5-9 times per year10 or more times per yearWhat are your doctors' names, and at which location do you see them? Please be specific. *Ex: Primary - Dr. Kacie Labik, 824 Main St, STE 307, Phoenixville, PA 19460How many prescriptions do you currently take? *0-4 Prescriptions5-9 Prescriptions10 or more PrescriptionsWhat is the name of the medication, dose, and form? (Type NA if you don't take any) *Ex: Losartan 50mg TABWhere do you pick up your medications if you need to go in-person? *Ex: CVS, 1501 Paoli Pike, West Chester, PA 19380Other InformationDo you have any underlying health conditions we need to consider when researching plans? *YesNoPlease specify the health conditions *Will all family members need to be included in this coverage? *YesNoPlease specify who needs coverage *Submit
