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Enter the information requested below for the insured plan members to be included in this proposal.
NOTE:
Items with a
*
are required
Primary Applicant Info
First Name:
*
Last Name:
*
Email:
*
Phone:
*
State:
*
City:
*
Address:
*
Comments:
*
Covered Members
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
LOS ANGELES
FirstName
Relationship
Gender
DOB
Zip Code
County
Tobacco
Prior
Coverage
Applicant
Self
M
F
*
*
LOS ANGELES
Spouse
Spouse
Domestic Partner
Life Partner
Same Sex Partner
M
F
*
*
LOS ANGELES
Dependent
Child
Adopted Child
Annultant
Brother/Sister
Brother/Sister-in-law
Collateral Dependent
Court Appointed Guardian
Cousin
Dependent of a Minor Dependent
Ex-Spouse
Father/Mother
Father/Mother-in-law
Foster Child
Grandfather/Grandmother
Grandson/Granddaughter
Guardian
Nephew/Niece
Other Relationship
Other Relative
Son/Daughter-in-law
Sponsored Dependent
Stepparent
Stepson/Stepdaughter
Trustee
Uncle/Aunt
Ward
M
F
*
*
LOS ANGELES
+ Add Dependent
+ Add Spouse
How many people are in your household?
1
2
3
4
5
6
7
8
9
10
You may qualify for a government subsidy under the Affordable Care Act.
Enter your estimated 2024 household income to see if you are eligible.
$
*
2024 Estimated Income
Product Type
Standard Individual & Family Coverage
Health Off-Exchange
Health On-Exchange
Short-Term Health
Payment Option:
Single Payment
Monthly Payment
Note:
Some insurance companies only offer a "Monthly Payment" option. You may not receive all available plans by selecting a single payment option.
Start Coverage On:
Last Day of Coverage:
Note:
Some insurance companies only offer a "Single Payment" option. You may not receive all available plans by selecting a monthly payment option.
Start Coverage On:
Coverage For Up To:
Renewable Options:
Please note all carriers may not offer repeating short-term enrollments.
There are currently no plans available for this term length.
Payment Option:
Monthly Payment
Start Coverage On:
Coverage For Up To:
1 Months
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Last Day of Coverage:
There are currently no plans available for this term length.
Requested Effective Date:
May 1, 2024
June 1, 2024
July 1, 2024
August 1, 2024
September 1, 2024
October 1, 2024
What is your current health plan premium? (optional): $
/month
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