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NYSOH

NYEP Application Form

Application#: A202504293576149
Please complete the form below accurately.
Inaccurate information may delay or result in the rejection of your application. All information provided will remain strictly confidential. For details on our privacy policy, security policy, and terms of service, please visit our Privacy Policy page.
Applications will be processed by a licensed brokerage and authorized partner of the New York State of Health.
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Please input full first name.
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Please input full last name.
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Please select birthday.
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please enter your vaild email.
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Please enter phone number.
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Please input WhatsApp number.
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Please input WeChat-or line ID.
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Please input.

New York Residential Address*

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Please input street address.
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Please input street address2.
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Please input city.
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Please input Postal / Zip Code.

Mailing Address *

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Please input street address.
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Please input street address2.
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Please input city.
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Please input Region/State/Province.
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Please input Postal / Zip Code.
Please input social security number.
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A social security number (if available) is required for income and identity verification purposes. All data will be kept strictly confidential.
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Please input Social Security Number.

Select your citizenship or visa status

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Please input green card USCIS number.

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Please select I-551 Green Card Expiration Date.
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Please input green card receipt number.

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Please upload your green card.
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Please input I-94 number.

Don't know where to find your I-94 number? Click Here

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Please input SEVIS ID.

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Please upload your I20.

Upload supported file (Max 15MB)

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Please input passport number.
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Please select passport expiration date.
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Please upload your passport.

Upload supported file (Max 15MB)

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Please input EAD USCIS number.

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Please input EAD card number.

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Please select EAD Expiration Date.
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Please upload your passport.

Upload supported file (Max 15MB)

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Please input I-94 number.

Don't know where to find your I-94 number? Click Here

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Please input Passport Number.
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Please select passport expiration date.
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Please upload your passport.

Upload supported file (Max 15MB)

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Please input specify.
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Please input I-94 number.

Don't know where to find your I-94 number? Click Here

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Please input Passport Number.
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Please select passport expiration date.
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Please upload your passport.

Upload supported file (Max 15MB)

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Please input full company name.
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Please input full street address.
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Please input city.
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Please input state.
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Please input Postal / Zip Code.
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Please input Pre-Tax Wages.
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Please input Average Hours Worked per Week.
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Please select employment start date.
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Please select employment end date.

The form below authorizes us to assist you with processing your application.

NY State of Health

New York State Department of Health

Corning Tower, Room 2580

Albany, NY 12237

 

Effective
I hereby designate Geoffrey Chua [AC0010601278] located at 4245 Upper Park, Fairfax, VA 22030 as myself and my household’s Broker of Record for health and dental plans offered through the NY State of Health Individual Marketplace. This designation of Broker of Record will remain in effect until I notify the Individual Marketplace in writing to the contrary. This designation revokes any previous designation of a Broker of Record with the NY State of Health Individual Marketplace.
Click in the box above to sign.
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Please complete your signature.
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Please input print name.

Last step! The following form is required by the New York State to verify your identity.

Identity Verification Form

1.Applicant Name

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2.Address

 {{formData.street_address}}

3.City

 {{formData.city}}

4.State

 NY

5.Zip Code

 {{formData.zip}}

6.Date of Birth(mm/dd/yyy)

 {{formData.date_of_birth}}

7.Social Security Number
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Please input social security number.

8.Telephone Number
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Please input telephone number.

These are examples of documents you can provide to verify your identity. Since you've already uploaded the documents, you may disregard this section.

9.Your signature
Click in the box above to sign.
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Please complete your signature.

10.Date (mm/dd/yyyy)
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Please select date.

11.Name (type or print legibly)
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Please input print name.

12.Relationship to applicant
Self
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