Sign Up for Obamacare

Date*

Household Size*

Total Household Taxable Income*

Subsidy?

Yes
No

Are you offered health coverage with yr/spouses employer?*

Yes
No

APPLICANT

Name*

Marital Status

Single
Married

Sex

M
F

Date of Birth

Age

Address

Street Address Address Line 2 City State / Province / Region ZIP County

Birth State / Country

Phone

Email

Currently Insured?*

Yes
No

SS#

Smoker

Yes
No

FL Resident

Yes
No

U.S. Citizen

Yes
No

SPOUSE / DOMESTIC PARTNER

Name*

Relationship

Spouse
Domestic Partner

Sex

M
F

Date of Birth

Age

Birth State / Country

Phone

SS#

Email

Smoker

Yes
No

FL Resident

Yes
No

Status

DEPENDENTS

Name

Social Security #

Sex

M
F

Date of Birth

Age

Birth State

Smoker?

Yes
No

Name

Social Security #

Sex

M
F

Date of Birth

Age

Birth State

Smoker?

Yes
No

Name

Social Security #

Sex

M
F

Date of Birth

Age

Birth State

Smoker?

Yes
No

Name

Social Security #

Sex

M
F

Date of Birth

Age

Birth State

Smoker?

Yes
No

Name

Social Security #

Sex

M
F

Date of Birth

Age

Birth State

Smoker?

Yes
No

Additional Information

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Payment

Paper Bill
Automatic Payment Option

Correspondence at?

Home Address
Email Address

Individual Under 65 Health Insurance

APPLICANT

SPOUSE / DOMESTIC PARTNER

DEPENDENTS

Additional Information