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Personal Information:

Additional Info:

Name *

First

Last

Spouse's Name (if there is a spouse) *

First

Last

Date of Birth *

Spouse's 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

Phone Number *

Who needs medicaid?

Do you need Coverage *

Yes No, I already have coverage

Does your spouse need medicaid? *

Do any dependents need medicaid? *

Marrtal status *

Dependent(s):

Who else dependents on your income? *

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

What's your race (optional) *

What's you spouse's 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) *

Would you like to us to submit this information for voter registration? *

Your Social Security Number *

If spouse needs coverage, what's your his/her Social Security number *

Medicare number if applicable ............ - 1EG4-TE5-MK72 *

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 *

Your spouse's annual gross income *

Your current income source *

Spouse's current income source *

Social Security or Disability Income *

Social Security or Disability Income (spouse) *

If self-employed, what type of work *

Self-employed spouse, type of work *

Employer name (Self if self-employed) *

Spouse's employer name *

Employer's phone# *

Spouse's employer's phone# *

How much do you pay monthly for student loans *

How much does spouse pay monthly student loans *

Do you smoke or use any other tobacco products *

Does your spouse smoke or use any other tobacco products *

Life Insurance (optional) *

How much (optional) *

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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