Calculate Your 2015 Second Lowest Cost Silver Plan Monthly Medical Premium

Complete the information below for each person in your tax household. For each person, check each month they enrolled in medical insurance through the Connector:

Name/NicknameDate of Birth (MM/DD/YYYY)Relationship to Primary Tax FilerAll of 2015Jan 2015Feb 2015Mar 2015Apr 2015May 2015Jun 2015Jul 2015Aug 2015Sep 2015Oct 2015Nov 2015Dec 2015