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Personal Information:

* Indicates required field

Name *

First

Last

Date of Birth *

Physical address *

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City

State

Zip Code

Country

P.O. BOX or Alternate Address *

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City

State

Zip Code

Country

Email *

Phone Number *

Who needs coverage?

Do you need Coverage *

Yes No, I already have coverage

Do any dependents need coverage? *

Additional Info *

How do you file *

Tell us about your tax dependent(s):

How many dependents will you file on your taxes *

List full name and date of birth for each dependent...... (add Social if dependent needs coverage as well) *

Dependent Address/if different *

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Line 2

City

State

Zip Code

Country

What's your race (optional) *

You can still verify each dependent's race

What was your assigned sex at birth? (Optional) This can be found on an original birth certificate or similar document. *

What's your gender identity? (Optional) *

What's your sexual orientation? (Optional) *

Your Social Security Number *

Does anybody applying for coverage have Disabilities that affect your ability to work or attend school. *

Does anybody applying for coverage need help with bathing, dressing, or using the restroom *

Please note, if you plan to file joint next year (for this 2021 tax year), you must fill out both sides of the electronic form going forward.

Tax Information:

Your annual gross income on 2024 taxes *

Your current income source *

If self-employed, what type of work *

Employer name (Self if self-employed) *

How much do you pay monthly for student loans *

Do you smoke or use any other tobacco products *

Please list any dependents who smoke *

Would you like additional benefits with your plan? (OPTIONAL) *

Dental Coverage Life Insurance

I agree to authorize James Gaffney to access and update my healthcare.gov account. I know and understand that this will effectively make said agent my agent of record. And I can, in the future rely on said agent for information and updates about my healthcare.gov account. *

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