Marketplace Questions General InformationName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Which county do you live in? (Not country) *Example: Delaware CountyEmail Address *Phone *Gender (Assigned at Birth) *MaleFemaleDate of Birth *Marital Status *SingleMarriedSpouse's Name *Spouse's Date of Birth *Income InformationTax Filing Status *SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdDo you claim any dependents? *YesNoDependent InformationDependent Name *Dependent's Date of Birth *What do you expect your HOUSEHOLD income to be in 2026 (gross)? *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 ExchangeCOBRAI'm Not InsuredDo you have a Health Savings Account (HSA)? *YesNoWhen do you need health coverage to begin? *Prescriptions and DoctorsIndicate all doctors/facilities you want to be in-network (including specialists):Doctor (or Facility) Full Name *Specialty *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Indicate all prescriptions you are currently taking:Medication Name *Please type N/A If you do not take medicationsDose *Please type N/A If you do not take medicationsForm *Select N/A if this doesn't applySelectTabletCapsuleSprayGelCreamOintmentPatchInjectionBottleInhalerN/ARefill Quantity *Type "0" if this doesn't applyRefill Frequency *Select N/A if this doesn't applySelect30 Days60 Days90 Days6 Months1 YearN/AOther InformationWill all family members need to be included in this coverage? *YesNoPlease specify who needs coverage: *Which is more important to you? *Lower premiums / higher out-of-pocket costsHigher premiums / lower out-of-pocket costsDo you have a preference on referrals to see specialists? *I want referralsI don't want referralsNo preferenceDo you have any underlying health conditions we need to consider when researching plans? *YesNoPlease specify the health conditions: *Is there anything else we should know about? *Submit
