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Are you running a family farm?

Gender

Date of Birth
mm	dd	yyyy

Tobacco Use
Y/N

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YesNo

Is this child legally disabled?

Spouse

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Is this child legally disabled?

Child

YesNo

Is this child legally disabled?

Child

YesNo

Is this child legally disabled?

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I am applying for a (under 18 s old)

for 2024 coverage was Nov. 1, 2023 to Jan. 16, 2024. To apply for coverage today, you must qualify for a Special Enrollment Period. Applications must be submitted with documentation of a qualifying life event.

* Zip Code

Email Address

* I am enrolling for coverage under

* Qualifying Reason

* Event Date

MM/DD/YYYY

I want my coverage to begin on

See if you qualify for lower costs
This information will be used to estimate your potential subsidy

Annual Household Income ($)	Family Members Residing in the Home (#)

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If you need assistance, our Sales Team is available to help you Monday – Friday 8:00am to 5:00pm at 855-494-2667.

For details about getting assistance in another language, view this multi-language document.

Licensing & Legal Privacy Policy

Attention: This website is operated by Common Ground Healthcare Cooperative and is not the Health Insurance Marketplace® website at HealthCare.gov. This website does not display all Qualified Health Plans (QHPs) available through HealthCare.gov. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace® website at HealthCare.gov.

Also, you should visit the Health Insurance Marketplace® website at HealthCare.gov if:

You want to enroll members of your household in separate Qualified Health Plans.
You want to enroll members of your household in dental coverage.

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