• Home
• Customer Service
• Your Information
• Our Community

Your Information

Eligibility for the Children's Health Insurance Program (CHIP) is based on family size and gross monthly income. If you are applying for the Pre-Existing Condition Insurance Plan (PCIP), there is no income requirement.

Applicant Information

First Name	Last Name
Email Address	Home Phone ()
State ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Date of Birth January February March April May June July August September October November December 12345678910111213141516171819202122232425262728293031 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Program Information

What is your family size? (parents and children under 19 years of age living in the home are counted as family members in determining family income. The unborn child of a pregnant woman also counts as a family member.)

1 2345678910

What is your Gross Monthly Income?

$

Would you like health insurance for yourself, your spouse, or your children over the age of 19? Health insurance is now available through the Pre-Existing Condition Insurance Plan (PCIP). You must be a U.S. citizen, have been denied health coverage because of a pre-existing condition, and have had no health insurance for the last 6 months.

Yes  No

Please note that all fields are required.