Open Enrollment Marketplace What is needed for Open Enrollment Marketplace? Streamlined intake for enrolling in ACA or private health plans Captures essential details for regulatory compliance and plan matching Suitable for individuals, couples, or families Ensures a flexible, efficient experience with thorough information collection Designed to maximize your access to affordable, high-quality coverage Open Enrollment Individual Coverage Questionnaire Newsletter Personal InformationTell us who needs coverage so we can match you with the right plans.First NameLast NameEmailPhone NumberZip CodeCountyDate of BirthTobacco User? Yes NoCurrent Coverage InformationWhat is your current health insurance coverage? ACA/Marketplace plan Private individual plan (PPO or other non-marketplace plan) Healthshare programHow do you feel about your current plan? I want to renew my current plan if still available I want to shop ACA options through the marketplace I want to shop Private PPO options I want to shop Healthshare optionsHousehold InformationWill your spouse be included on the health insurance plan? Yes NoSpouse InformationSpouse First NameSpouse Last NameSpouse Date of BirthIs your spouse a tobacco user? Yes NoDependentsDo you claim any dependents on your taxes? Yes NoWill any of these dependents need health insurance coverage? Yes No Dependent Information First Name Last Name Date of Birth Tobacco User? – Select –YesNo Dependency VerificationDoes anyone claim you as a dependent on their taxes? Yes NoTax InformationDo you wish to apply for subsidies on the marketplace? Yes NoHow do you file your taxes? Jointly IndividuallyTotal estimated household income you will report on your taxes, or income a parent will report on their taxes if you are being claimed as a dependent $Provider InformationPlease list the doctors you want to make sure are in-networkPrescription InformationPlease list any prescriptions you are taking that you want to make sure are covered I agree to the Terms and Conditions and Privacy Policy. Submit Questionnaire
