Open Enrollment 2026 Screening - Save Time and Skip the Line!
Please answer the questions below regarding your current situation. If you're uncertain about how to respond to any questions, you can schedule a consultation through our automated system by calling 732-523-1789. Follow the prompts to schedule an appointment regarding open enrollment and private health insurance options.

Note for NJ FamilyCare Participants:
If you are currently active on NJ FamilyCare and have not received a termination letter, do not fill out this form, even if you believe you are no longer eligible. You will be eligible for a Special Enrollment Period to enroll in private health insurance once you receive a termination notice. If you need private insurance for 2026, please contact the LRRC for guidance. 

If you receive a NJ FamilyCare renewal packet, do not ignore it! All renewal packets must be returned by the due date.
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Email *
What is your first and last name? *
Can we contact you through e-mail? (Response time for email is 2 days, response time for phone is 4 days).  *
Preferred Contact Number *
Preferred E-mail Address *
Home Address *
City *
State *
Zip Code *
What is your family size? *
Count everyone who will appear on your tax return (Form 1040). Do not include unborn children.
Is anyone in your family pregnant? *
Who Needs Insurance (Check All That Apply)? *
Required
What is your birthday? *
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What is your spouse's birthday?
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What is your current medical insurance? *
List all the insurance providers for all family members seeking coverage. Include Medicaid in any State, Commercial, or Private Insurance. Write "uninsured" if you do not have insurance. 

If you are currently active on NJ FamilyCare and have received a termination letter, include the termination date in your response.

If you are currently active on NJ FamilyCare and have not received a termination letter, see instructions above. Do not complete this form. 
How much income will your family receive in 2026 (estimated)? *
Enter the amount of income that anyone on your tax return is expected to receive in 2026. 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 calculate this number. Please note that this projected amount can change throughout the year. The number you are providing is an estimate.
Did you or anyone in your household ever receive insurance through Get Covered New Jersey? *
If you are currently receiving insurance through Get Covered New Jersey, do you have any changes of income since last year's application?
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Does your or your spouse's 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 confirmed this information with your employer. *
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 confirmed this information with your employer. *
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 confirmed this information with your employer.
Please enter a monthly dollar amount
If an employer does give you the option of purchasing insurance, what is the cost of the cheapest COUPLE plan?  Do not answer this question until you confirmed this information with your employer.
Please enter a monthly dollar amount
If an employer does give you the option of purchasing insurance, what is the cost of the cheapest FAMILY plan?  Do not answer this question until you confirmed this information with your employer.
Please enter a monthly dollar amount
Additional notes for the LRRC Case Manager
Please use this space to write any additional information that will help the LRRC understand your situation.
Navigator Authorization *
I give permission to Lakewood Resource and Referral Center, Inc. (LRRC), to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information (PII) to perform the following duties of a Navigator:
  • Inform me and/or my authorized representative about the full range of health coverage options and insurance affordability programs for which I am eligible;
  • Help me complete my application for health coverage in a Qualified Health Plan (QHP) through NJ FamilyCare, Get Covered NJ, and/or other private health insurance options;
  • Help me enroll in a health insurance plan. Examples of PII include my date of birth, social security number, and immigration status. 
The LRRC Navigator will request and access only the minimum necessary PII necessary to perform authorized Navigator functions. I understand that I may revoke this authorization at any time and will notify the LRRC if I choose to revoke my authorization. I understand that LRRC Navigators have the following responsibilities and will perform the following functions: 
  • LRRC Navigators will inform me and/or my authorized representative about the full range of health coverage options and insurance affordability programs for which I may be eligible and may help me apply for health coverage through NJ FamilyCare or Get Covered NJ.
  • LRRC Navigators will inform me of any possible conflicts of interest they might have.
  • LRRC Navigators cannot choose a health insurance plan for me.
  • LRRC Navigators are required to act in my best interest.
  • LRRC Navigators will follow privacy and information security standards when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII and/or the PII of my authorized representative. 
  • The assistance LRRC Navigators provide is based only on the information I and/or my authorized representative provide. If the information provided is inaccurate or incomplete, LRRC Navigators will not be able to help me properly. LRRC Navigators will not be held liable for incorrect information provided by a consumer.
  • If LRRC Navigators cannot assist me, they may refer me to another person or organization who can help me, or to the Get Covered NJ Call Center.
  • LRRC Navigators will not charge me a fee for any assistance provided.
I authorize LRRC to maintain or store my Personally Identifiable Information (PII) to ensure LRRC’s continuous ability to provide quality services. I understand that I do not have to give LRRC more information than I choose to provide.  
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