Paper Applications

 

If you prefer paper applications to the online application, Customer Support Center (toll-free at 1-855-899-9600), or a Navigator or Broker, you can download and print PDF versions of the appropriate application packet below. Each packet contains multiple forms, so please be sure to view each document in the appropriate column.

To compare your options side-by-side before making your plan selection, visit our online Plan Comparison Tool or download our Plan Comparison Brochures.

If you are not sure what information to enter please call our Customer Service Center toll-free at 1-855-899-9600. They are available Monday – Friday from 8 am to 8 pm.   Your information will be treated with complete confidentiality.

TO AVOID DELAYS PROCESSING YOUR APPLICATION:  If you choose to complete the paper application below and mail it to us, please make sure you have completed every field before signing and mailing to: Vermont Health Connect, 280 State Drive, Waterbury, VT 05671-8100

 

 

Applications for 2017 Health Coverage

Individual Application
(with financial help)

Individual Application
(with NO financial help)

Application for Health Coverage and Help Paying Costs

Application for Health Coverage with No Financial Help

Appendix A - Assistance Completing the Application (if applicable)

Appendix A - Assistance Completing the Application (if applicable)

Appendix B - American Indian or Alaska Native Family Member (if applicable)

 

Appendix C - Employer Coverage Tool (if applicable)