If you are including more than one person on this application, please include how each family member is related to each other (parent, son, daughter, brother, sister, etc.).
Consent for Verification
Permision to Let Covered California Verify Your Information
Covered California checks other agencies' computer records to verify citizenship, satisfactory immigration status, tax information, and other information related only to eligibility to see if you and other people on this application qualify for health insurance.
Terms and Conditions Agreement
To submit your application, read the agreement here and enter your eSignature in the space below. When you enter your eSignature, it means you are sure about the health insurance plans you chose and have read all the terms and conditions.
Terms and Conditions: I understand that every participating health plan has its own rules for resolving disputes or claims, including, but not limited to, any claim asserted by me, my enrolled dependents, heirs, or authorized representatives against a health plan, any contracted health care providers, administrators, or other associated parties, about the membership in the health plan, the coverage for, or the delivery of, services or items, medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), or premises liability. I understand that, if I select a health plan that requires binding arbitration to resolve disputes, I accept, and agree to, the use of binding arbitration to resolve disputes or claims (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law) and give up my right to a jury trial and cannot have the dispute decided in court, except as applicable law provides for judicial review of arbitration proceedings. I understand that the full arbitration provision for each participating health plan, if they have one, is in the health plan’s coverage document.