Please check all, which apply. (All are required for eligibility)
I have been enrolled in an employer's health plan or in extended COBRA coverage after employment, during the past 18 months or my break in coverage has not exceeded 63 days.
My previous insurance coverage was under a group health plan, government plan, or church plan.
My previous insurance coverage was not terminated because of fraud or failure to pay my premiums.
I'm not enrolled in any other coverage plan. (This also applies if you are eligible for group coverage under other health insurance such as through your spouse's employer or health insurance under Medicaid or Medicare.)
