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ACA Application

Name *

Last name

Date of birth

Phone *

gender

Género

Male
Female
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Email *

Address

Street Address

City

State

Country

Country

Postal code

Source of Income

W2

1099

Other

Immigration Status

U.S. Citizen

Resident

Employment Authorization Document (EAD)

Other

Marital Status

Estado civil

Soltero (a)
Casado (a)
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Who will be applying for coverage?

¿Quiénes aplicarán a la cobertura?

Self only
You and your spouse
Spouse only
Entire family
Dependents only
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Spouse’s Name

Spouse’s Date of Birth

Is spouse applying for insurance?

¿El conyuge aplicará al seguro?

Yes
No
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Spouse’s Gender

Género del conyuge

Male
Female
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Do you claim dependents on your taxes?

Tiene dependientes en sus taxes

Yes
No
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Will you file your taxes as Married?

Declarará impuestos como casado

Yes
No
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How many dependents are you claiming?

Cuantos dependientes declarará en sus taxes

1
2
3
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Dependent #1 Full Name

Date of Birth of Dependent 1

Gender of Dependent 1

Género del dependiente 1

Male
Female
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Will dependent 1 be applying for coverage?

¿El dependiente 1 necesita seguro?

Yes
No
Have Medicaid
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Dependent #2 Full Name

Date of Birth of Dependent 2

Gender of Dependent 2

Genero del dependiente 2

Masculino
Femenino
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¿El dependiente 2 necesita al seguro?

¿El dependiente 2 necesita al seguro?

Si
No
Tiene Medicaid
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Dependent #3 Full Name

Date of Birth of Dependent 3

¿El dependiente 3 necesita seguro?

¿El dependiente 3 necesita seguro?

Si
No
Tiene Medicaid
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gender dependient 3

Genero del dependiente 3

Male
Female
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Familiar anual income

Ingreso anual familiar aproximado

$0 - $25,000 USD
$25,001 - $42,000 USD
$42,001 - $55,000 USD
+ $55,000 USD
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Immigration Status of Dependent #1

U.S. Citizen / Resident

Permiso de trabajo

Otro

Immigration Status of Dependent #2

Ciudadano / Residente

Permiso de trabajo

Otro

Immigration Status of Dependent #3

Ciudadano / Residente

Employment Authorization Document (EAD)

Other

Additional notes for the agent

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