Enter Information About Your Household

1. Select a State ?

Enter your zip code

Your county is .

Select county

2. Is coverage available from your or your spouse’s job??

3. Number of people in family?

4. Which members of your family are enrolling in Marketplace coverage??

4. Number of adults (21 to 64) enrolling in Marketplace coverage?

5. Number of children (20 and younger) enrolling in Marketplace coverage

Notes