Request Health Insurance Assistance

First Name *

Last Name *

E-mail *

Phone Number

Area Code Phone Number

Zip code *

City *

County *

Gender *

Birth Date *

Month Day Year

Tobacco in past 6 months *

No Yes

Add Spouse/Domestic Partner *

Spouse Gender *

Spouse Birth Date *

Month Day Year

Spouse Tobacco in past 6 months *

No Yes

Add child *

Child 1 Gender *

Child 1 Birth Date *

Month Day Year

Child 1 Tobacco in past 6 months *

No Yes

Add another child *

Child 2 Gender *

Child 2 Birth Date *

Month Day Year

Child 2 Tobacco in past 6 months *

No Yes

Add a third child *

Child 3 Gender *

Child 3 Birth Date *

Month Day Year

Child 3 Tobacco in past 6 months *

No Yes

Add a fourth child *

Child 4 Gender *

Child 4 Birth Date *

Month Day Year

Child 4 Tobacco in past 6 months *

No Yes

Add a fifth child *

Child 5 Gender *

Child 5 Birth Date *

Month Day Year

Child 5 Tobacco in past 6 months *

No Yes

Add more children *

Gender and Date of birth of any additional children

Do you want to find out if you'll qualify for subsidies or tax credits?

I definitely won't qualify for a tax credit and would like to enroll off exchange. I understand this disqualifies me for any available tax credits. Yes, I might qualify for a tax credit.

Your household of

Select the number corresponding to the number of people in your tax household.

might qualify with an income below

This field displays the highest income to qualify for a tax credit based on your selected tax household size.

Based on these tax credit income limits

I don't want to apply for up front financial assistance at this point. If I end up qualifying, I'll claim the tax credit when I file my tax return. I want to enroll through the exchange without financial assistance. Yes, I will qualify and I would like to apply for financial assistance through the exchange (Connect for Health Colorado).

Will everybody in the tax household be enrolling in health coverage?

Based on the income eligibility guidelines on this page: (http://bit.ly/chp-guidelines) --- Do you anticipate having any children who qualify for CHP+? *

Who is in the household, but not enrolling?

Why do you need new coverage?

OPEN ENROLLMENT (Effective 1/1/2020 or 2/1/2020) Coverage is ending Moving from a different area Marriage Child Birth / Adoption Becoming US Citizen

Have you ever created an account with Connect for Health Colorado (the exchange)? *

What is your current coverage - or the last coverage you had?

Can you describe (in your own words) the type of policy you're looking to get?

To calculate your financial assistance/subsidies, what do you expect your household income to be?

Are you a human? *