Email address *
Open Enrollment 2021 Screening - Save Time and Skip the Line!
Answer the below questions about your current situation. If you need help determining the answer to any of the below questions, please schedule an appointment through our automated scheduling system by calling 732-523-1789. Follow the prompts to schedule an appointment to discuss open enrollment and private health insurance options.
What is your first and last name?
Can we contact you through e-mail? (Response time for e-mail is 2 business days. Response time for a phone call is 4 business days.) *
Best Contact Number *
Preferred E-mail Address *
What is your family size? *
Count everyone who will appear on your tax return (Form 1040)
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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Is anyone in your family pregnant? *
Did you file a tax return last year? *
How much income will your family receive in 2021 (estimated)? *
Enter the amount of income that anyone on your tax return is expected to receive in 2021. 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.
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.
Did you ever receive insurance through The Marketplace? *
Do you 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 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
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.
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