Your Information

Applications must be submitted by December 21 for coverage beginning January 1, 2015. After selecting
and enrolling in a Covered California health plan, monthly subsidy payments are made directly to your
health insurance company. If you would like to enroll in Covered California, complete the short form below. We will calculate your monthly subsidy and help you select a health plan.

Applicant Information

First Name
Last Name
Email Address
Phone
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What is your family size?
What is your Income?
$

Please note that all fields are required.