Apply for Health Insurance

Health Insurance Application Form

Main Healthcare Insurance

Agent Details

Select your referral LSCO agent

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Personal Details

Name

First Name

Last Name

Date of Birth

(For eligibility and premium calculation)

SSN

(Used to verify identity and income for subsidy eligibility)

Upload ID/DL

Phone Number

Email Address

Residential Address

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Household Information

(To determine eligibility for subsidies and coverage levels)

Do you have household members?

You will list the members as dependents in the next section

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Dependent 1

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

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Dependent 2

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

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Dependent 3

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

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Dependent 4

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

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Dependent 5

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

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Employment Information

Employment Status

Employer’s Name

Optional

Monthly Income

(Required for subsidy eligibility calculation)

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Current Insurance Status

Dropdown

If yes, name of the provider and type of coverage

(Optional)

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Consent and Acknowledgements

I confirm that the information provided is accurate to the best of my knowledge. I understand that false information may affect my eligibility for coverage.

I consent to receive communication regarding my application via email, phone, or text message.

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Signature Section

Applicant’s Signature

Date Signed

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If you are human, leave this field blank.

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