TEST VERSION — do not enter real information. This version accepts only test numbers.

Client Intake Form

This form collects the information your agent needs to prepare a health insurance application. Submitting this form does not confirm enrollment or coverage.

This form will be used solely by your enrolling agency for the purposes of enrolling you and any additional applicants into an insurance plan(s) or products of your choice.

Primary Applicant

Primary Applicant First Name (required)

Primary Applicant Last Name (required)

Primary Applicant Date of Birth (required)

Primary Applicant Social Security Number (required)

Primary Applicant Home Address (required)

Street address (include apartment or unit if any) (required)

City (required)

State (required)

ZIP code (required)

Primary Applicant Mailing Address (required)Same as primary home address

Street address (include apartment or unit if any) (required)

City (required)

State (required)

ZIP code (required)

Primary Applicant Phone Number (required)

Back Up Phone Number (Optional)

Primary Applicant Email Address (Optional)

Household and income

How many people will be a part of your household when you file your federal income taxes for the year? (Everyone that will be on the primary applicant's tax filing with the IRS for the year of coverage) (required)

Count the people who will be on the primary applicant's tax filing for 2027, as described in parentheses above, not everyone who lives at the same address. Every dependent you will claim must be counted, even a dependent who lives somewhere else or is not applying for coverage. Do not count people who live with you but will not be on that tax filing. Your agent will confirm this number and your income with you after you send this form.

Generates a highly accurate estimate of the likely cost of your access to coverage.

Your agent prepares this estimate from the household size and income you give here; it is not a quote or an eligibility decision.

See the 2026 income guidelines (used for 2027 coverage) for your household size

2026 Federal Poverty Guidelines — used for Coverage Year 2027 (48 contiguous states and DC)
Percent of the guideline	Yearly household income

Each additional person adds $5,680 to the guideline amount. Alaska and Hawaii use different guidelines; this chart is for the 48 contiguous states and DC. Figures are yearly household income.

Chart figures are rounded to the nearest dollar. The income ranges in the question below use the exact percentage, so a range can start one dollar above the matching chart figure. Choose the range that includes your income: the range, not the chart, is what counts.

Your income estimate

I attest that the household income I selected is my accurate estimated projection of my household's income for benefit year 2027. (required)Type your full legal name (required)

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TEST VERSION — do not enter real information. This version accepts only test numbers.

Questions? Call (866) 949-3404

Client Intake Form

Primary Applicant

Household and income

Additional Applicant 1