Enrollment

Enrollment Trigger

Enrollment Trigger: *

Date of Event:*

1. The Basics

Name : *

Enter your full name

Email :*

Enter a valid email

Phone Number :*

Address - Residence : *

the topic of your message

City :*

Zip Code :*

Address - Mailing if different:*

Enter a brief message

2. Household
Household includes all members that file taxes together on on 1040 tax form in the current year.

Number of Family Members :*

3. Tax Status

How does household file taxes? *

Do you plan to file for this year and next? * YesNo

4. Eligibility

Are you offered Affordable health insurance through an Employer? * YesNo

Is everyone a US Citizen? * YesNo

For non-US-Citizen list members, document type ID# , expiration date and card id # *

Does any member have Medicare? * YesNo

Is any member Disabled? * YesNo

Medical expenses in past 3 months? *YesNo

Member of a Federally Registered Indian Tribe? * YesNo

Any children in foster care? * YesNo

Are any children full time students? * YesNo

Is any member pregnant? * YesNo

Is any member involved in a lawsuit? * YesNo

5. Income

Best household Estimate for 2020 Income? *

Income Breakdown :*

Please type your income for example Person A self- employed writer $ 30,000 Person B - W2 employee $ 575 per week employer ABC company - 123 George # Ave Los Angeles CA 90005

6. Plan Selection

You can run your quote HERE. Make sure to put in income estimate and select "On Exchange" to see tax credit effect.

Carrier *

Metal Level *

Network *

Dental (if enrolling)

Carrier *

7. Almost Complete!

Covered California requires that your identification has been identified. Please upload a Driver License, CA ID or passport picture *

Upload copy of official picture ID (DL, State, passport, etc)

E-Signature *

By signing, you agree to these terms and conditions. Today's Date *

What to Expect:

Email Confirmation – Usually received within 24 hours (business hours 9am-5pm Monday-Friday) of completed application with plan, rate, and effective date.

Covered California Confirmation by Mail – Usually within 5 business days from email confirmation

1st Invoice from Carrier – Usually within 5 days of Covered Ca letter