If you haven't already filled out the application on Healthcare.gov please do so prior to filling out this form. You can find the application here.

Are you applying for health insurance assistance for 2021?

If you're needing assistance with 2020 and Covid-19 related issues please head over to the "Covid-19 Relief" page.

Contact Information

Is your mailing address the same as your home address?

Choose your preferred contact method

Financial Information

  • How much money do you make a year?

Please write the same value you wrote on your Health Insurance Marketplace Application

  • Which insurance company's plan did you choose?

Look at your Health Insurance Marketplace application. If you don't know write "unknown"

  • What is your plan number or name?

Write "Unknown" if you don't know

  • What is your Member number?

Write "Unknown" if you don't know

  • What is your Health Insurance Marketplace application number found on the Healthcare.gov website?

Write "Unknown" if you don't know

  • How many people will be covered under this plan?

Insurance History

  • Did you have a Health Insurance Marketplace plan last year?

  • Look at your Health Insurance Marketplace application. How much is your monthly premium responsibility?

  • Did you select the “Advance Payment” option for your Advance Premium Tax Credit? You must select the “Advance Payment” option in the Health Insurance Marketplace to be eligible for financial help from Health Insurance Assistance Inc.

  • Has Health Insurance Assistance Inc. helped you pay for health insurance Before?

  • Look at your Health Insurance Marketplace application. Find the Premium Tax Credit section. How much is the monthly premium tax credit?

  • What month will you insurance coverage begin?

  • How did you first hear about Health Insurance Assistance Inc.?

Read & submit this application

*You must agree to all of the following conditions to submit your application.

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