Email address *
Open Enrollment 2019 Appointment Screening - Save Time and Skip the Line!
Answer the below questions about your current situation. If all questions are answered, you will be contacted by the end of the next business day. You will only be contacted if your application is complete.

If you need help determining the answer to any of the below questions, please call our office to request an appointment. We can be reached at 732-942-9292.

What is your first and last name?
Your answer
Can we contact you through e-mail? *
Best Contact Number *
Your answer
Preferred E-mail Address *
Your answer
What is your family size? *
Count everyone who will appear on your tax return (Form 1040)
Your answer
Who Needs Insurance (Check All That Apply)? *
Required
How Old Are You? *
Your answer
How Old is your Spouse?
Your answer
Is anyone in your family pregnant? *
Did you file a tax return last year? *
How much income will your family receive in 2019 (estimated)? *
Please enter the amount of income that anyone on your tax return is expected to receive in 2019. For those that receive income from an employer, enter the amount expected to receive before taxes. For those that are self-employed or receive rental income, enter the estimated net income (after expenses). For those who are self-employed, we recommend speaking to your accountant to get this number. Please note that this projected amount can change throughout the year. The number you are providing is an estimate.
Your answer
What is your current medical insurance? *
List all the insurance providers your family is currently covered by, including Medicaid in any State, Commercial or Private Insurance. Write "uninsured" if you do not have insurance.
Your answer
Did you ever receive insurance through The Marketplace? *
Does you or your spouses employer offer the option of medical insurance? Enter yes whether or not you would consider enrolling in the plan, and regardless of the price. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER. *
If an employer does give you the option of purchasing insurance, does the employer also offer an option for the spouse to join the plan? Enter yes whether or not you would consider enrolling in the plan, and regardless of the price. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER. *
If an employer does give you the option of purchasing insurance, enter the amount it would cost the EMPLOYEE to buy the CHEAPEST possible EMPLOYEE only plan. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER.
Please enter a monthly dollar amount
Your answer
Additional notes for the LRRC Case Manager
Please use this space to write any additional information that will help the Case Worker understand your situation.
Your answer
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