Apply for Health Insurance

Health Insurance Application Form

Main Healthcare Insurance

Agent Details

Select your referral LSCO agent

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

Maximum file size: 20MB

Phone Number

Email Address

Residential Address

City

State/Province

Zip/Postal

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

Dependent 1

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

Dependent 2

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

Dependent 3

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

Dependent 4

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Do you want to add another dependent?

Dependent 5

Name

First Name

Last Name

Date of Birth

Relationship

(For family coverage)

Employment Information

Employment Status

Employer’s Name

Optional

Monthly Income

(Required for subsidy eligibility calculation)

Current Insurance Status

Dropdown

If yes, name of the provider and type of coverage

(Optional)

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.

Signature Section

Applicant’s Signature

Clear

Date Signed

If you are human, leave this field blank.

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