Health Plan Pre-Enrollment Eligibility Verification Form
Please complete this form to verify your eligibility to proceed with health plan pre-enrollment. All information is preliminary and subject to later review.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a current resident of the state where this health plan is offered?
*
Yes
No
Do you currently have any active health insurance coverage?
*
Yes
No
What is your primary eligibility basis for this health plan?
*
Please Select
Employment with a participating employer
Dependent of an eligible employee
Self-employed
Other
If you selected 'Other', please specify your eligibility basis.
Verify Eligibility
Should be Empty: