Individuals and Sole Proprietors

How to Apply

Applications

You may print out the application and complete it, or you may complete the application online and then print it out. Applications cannot be submitted online or via e-mail.

• Application for Individuals and Sole Proprietors (PDF format)

How to Submit Your Application

Make sure you:

• Complete and sign the application.
• Enclose proof that:
  1. Your household meets the income guidelines,
  2. You are a New York State resident, and
  3. You or your spouse has worked at some point within the past 12 months.
• Enclose a check for the first month’s premium, made payable to the insurer to which you are applying.

Mail your completed application directly to the insurance company through which you want Healthy NY coverage. Please do not mail your application to the Department of Financial Services, as this will delay the application process. For a list of insurance companies, their addresses, and premium rates, visit the Insurers and Rates page.

When Coverage will Start

If the insurance company receives your completed application, supporting documentation and first month’s premium payment by the 20th of the month, coverage will start the first of the following month.

Application Status

The Department of Financial Services does not process Healthy NY applications. Please direct all questions regarding application status to the insurance company to which you applied. For your insurance company’s contact information, visit the Insurers and Rates page.

If you are unable to print the application, please contact our toll-free hotline at 1-866-HEALTHY NY (1-866-432-5849) or e-mail us to request an application.