Health Insurance Request Name(Required) First Last Our process is email first, if we can't get ahold of you that way, we'll text you. If we are unable to connect with you that way, we will send you a letter. Lastly, if those all of these fail, we invite you to come to our office during business hours. The first 2 modes of communication are optimal for speed. Cell Phone(Required)Email(Required) Enter Email Confirm Email Opt out of text messages No Yes Home PhoneDate Of Birth(Required) Month Day Year Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required)Can you login to MNSure Account and assign me as your assister?(Required) Yes No I'm not sure Assign us as the assister Please go to MNSure.org to find exact step-by-step instructions on how to assign the assistor. Then come back to this form to continue the process.Please reach out to MNSure You can call them at 651-539-2099 or 855-366-7873 or go to their website by clicking here to find out if you have an account with them. Then come back to this window to complete the process. Directions to set up account Click Mnsure.org to learn how to set up your account on MNSure. Once you have completed your account set-up, come back to this window to complete the process. Please note: Do not complete an application.Have you assigned me as your assister?(Required) Yes No Thank you for your interest in working with us. We look forward to helping you when you have assigned us as your assister. Please see above for directions to complete this step. If you are not interested in this, we do have direct pay options. Do you have any other members of your household (for tax purposes)?(Required) Yes, either I'm claiming other people and myself or someone else is claiming me. No, and no one else claims me. I'm not sure How many adults (not including you)(Required)Please enter a number from 1 to 10.Fill this in even if you're not sure. How people under 18?(Required)Please enter a number from 0 to 10.Medications(Required) I take no medications I take a few inexpensive medications I take expensive medications (1 or many) Providers(Required) I'm open to going to any doctor I want to keep my current doctors I'm not sure CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
