Application for Individual Coverage
Who is this for?
If you're ready to apply for one of our individual and family plans, use this application.
Found one of our individual and family plans that's right for you? Although applying online is usually the best way to sign up, you may be able to use this paper application to apply. Here's how to get started.
What to do:
First, make sure you can buy a plan. You can only do this:
- During open enrollment. For 2015, open enrollment is Nov. 15, 2014 to Feb. 15, 2015.
- If you've had certain changes in your life circumstances that mean you're eligible for special enrollment.
Second, make sure you're not eligible for a subsidy. That's financial assistance many people can get from the government that lowers the cost of your plan.
You can find out if you qualify by taking a few minutes to use our subsidy estimator. When it's time to file your taxes, you'll get a 1095 form. If you get a subsidy, you'll need the information from the form to complete your tax return.
If you're not eligible for a subsidy, you can apply online or use this application to apply for any of our 2015 plans except multi-state plans.
If you want to apply for a plan using a subsidy or a multi-state plan, please apply online or call a health plan advisor at 1-855-237-3501. Have a look at our individual and family health plans for more information.
What you'll need:
- Social Security number or tax ID number and date of birth for everyone who'll be covered by the plan
- A credit card if you want to make your first payment that way
- A printer to print the form
- An envelope and postage to mail the form