Summary of State Law Requirements Addressing 2026

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2. Begin by entering the applicant's full name, including first, middle initial, and last name in the designated field.
3. Input the applicant’s nine-digit Social Security Number in the corresponding box.
4. Provide a complete home address for the applicant, including street address, city, state, and ZIP code.
5. Enter a daytime telephone number with area code for contact purposes.
6. Fill in details about the health insurance policy: name of insurance carrier, policy start date, and premium billing address.
7. Indicate the total monthly premium amount and policy number in their respective fields.
8. Answer eligibility questions regarding Medi-Cal enrollment and other relevant criteria by checking 'Yes' or 'No' as applicable.
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