Important information about this application

Before you fill out your application, please read the important information and tips below. Then, choose the application that's right for you at the bottom of this page.

  • If you use Internet Explorer as your browser:
    • You will be able to submit your application online via a secure delivery system.
    • You will not be able to save your application or retrieve it after you click SUBMIT. Please print a copy of your application for your records before clicking SUBMIT.
  • If you use Firefox, Chrome, Safari or another browser (not Internet Explorer):
    • You will NOT be able to submit your application online.
    • You must print the application and send it to us by mail or fax (see application for details). Do not click the SUBMIT button on the application, because your information will not be sent and will be lost.
  • We are not able to support the use of this form on iPads (or other tablets) or mobile devices at this time.


1) You will only have 1 hour to complete the application - be prepared before you start.

Since you will only have 1 hour to complete the application online and since you will not be able to save the application online , it's important to be prepared. It's a good idea to gather the following information before you start your application.

For each person who is applying for health insurance, you must include:
  • Birthdate
  • Social Security number (if you have one)
  • Alien Resident number (if you have one)
If you choose to apply for financial savings, include the following information for all applicable household members:
  • Tax-filing information
  • Income information

By gathering this information before you start your application, you should be able to finish filling it out within 1 hour. After 1 hour, your information will be lost and you will need to start over. If you think you'll need more time, you can print the application, fill it out and then mail or fax at your convenience.

2) Protect your identity

If you are using a shared computer, fully close the browser after submitting your application. This will keep other users from having access to your personal information.

Your browser MUST have javascript enabled to submit this application.