Individual & Group

Information just comes to us, and we will talk it over with you.
James, Sara, Tom,
Robin, or Sean

Preliminary Information

Reason for enrollment: Open Enrollment
  ICHRA (Employer Offered)
  Loss of Current Coverage
  Off Exchange to On Exchange
  Other: (Reason)
Anticipated Start Date?:
Do you already have a Connect for Health CO Account? YesNo
Connect For Health User Name:
Connect For Health password:
Have you been recently denied by Medicaid?: YesNo
Medicaid #1B Case number:
(if applicable)

Primary Applicant

Applicant's Name: First Middle Last
Date of Birth: (mm/dd/yyyy)
Gender: Female Male
Have you used Tobacco in the last 12 months: No Yes
Social Security Number:
Are you a US Citizen: No Yes
If You are not US Born we will need a copy of your Citizenship, Green Card, US Resident ID Number, Expiration Date, Entry Date, Etc.:
Are you a Native American: No Yes
Phone Contact Number: Primary Secondary
Primary Applicant's Email Address:
What is your Marital Status: Single Married Civil Union/Common Law Divorced
Are you Pregnant: No Yes
Applying for Health Insurance coverage: No Yes

Applicant's Physical Address

(No P.O. Box numbers)

Applicant's Mailing Address

(If Physical Address is not Mailing Address)
(if different from above)
Home Street Address 1:
(Not a P.O. Box#)
Home Street Address 2:
Home City:
Home State:
Home Zip Code:
Home County:
(if different from above)
Mailing Address 1:
(P.O. Box#)
Mailing Address 2:
Mailing City:
Mailing State:
Mailing Zip Code:
Mailing County:

Tax Credit Application

Number of people (including yourself) on this year's tax return:
How will you be filing your Taxes?
Will you be claimed as a dependent on someone else's tax return? No Yes
Have you or any member on your tax return received any unemployment income this year? No Yes

Sources of Income: Primary Applicant

Estimate "Employment" income for the year:
If you have received unemployment, estimate how much for the year:
If you receive investment income, estimate how much for the year:
Name of your employer:
Address of your employer:

Sources of Income: Spouse (if applicable)

Estimate your Spouse's "Employment" income for the year:
If your Spouse received unemployment,
estimate how much for the year:
If your Spouse receives investment income,
estimate how much for the year:
Name of your Spouse's employer:
Address of your Spouse's employer:

Sources of Income: Dependent Children

If your dependent child(ren) received income,
estimate how much for the year:

Applicant(s) total income for year applying for coverage

Estimated gross income for this year:

Closing Information

How did you hear about us?
Who is your Agent?
Add a note to this Pre-Application:

By signing this application you are giving permission to open a Connect for Health CO account for you. By signing your name below you are authorizing to act as your Broker of Record and we will assist you in the process of obtaining and servicing your health insurance plan. Final acceptance or approval of your application is dependent on the Exchange/Carrier as well as prompt payment of policy premiums. We do our very best to get your application processed; you must hold us harmless for system failures beyond our control. Our services are paid by the Carrier and there is no cost to you.

Electronic Signature:  (Type Your Name)
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IMPORTANT READ - will be emailing you once we have completed your enrollment. It will be your responsibility to make sure you pay your first premium on time and before your policy's effective date. Failing to pay your policy premiums may result in your policy termination and may prohibit you from having coverage until the next Open Enrollment.