Get Khbe 111 Form

This guide provides step-by-step instructions for filling out the Khbe 111 Form online. This application is designed for single individuals seeking health insurance coverage and assistance with costs in Kentucky.

Follow the steps to successfully complete the Khbe 111 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal details in Section 1, including your first name, middle initial, last name, and suffix as it appears on your Social Security card.
3. Enter your Social Security Number (SSN). If you do not have an SSN, select the reason for not providing it from the options given.
4. Fill in your date of birth in the format mm/dd/yyyy.
5. Select your gender by marking either Male or Female.
6. Indicate whether you have used tobacco at least four times a week in the past six months.
7. Confirm your residency in Kentucky and your intention to remain in the state.
8. Provide your home address. If you do not have one, check the appropriate box and enter a mailing address if different.
9. Input your primary and secondary phone numbers, and check the box if you wish to receive text alerts.
10. Select your preferred spoken and written language.
11. Respond to questions regarding pregnancy and any current health coverage you may have.
12. For your current job and income, provide details about your employers and your gross income before taxes.
13. Fill out the section regarding other sources of income and any relevant deductions.
14. Complete other healthcare coverage details if applicable.
15. Sign and date the application to confirm that all information provided is accurate and true.
16. Review your application for completeness, then save changes and download, print, or share your form as needed.

Complete your health coverage application online today and explore your insurance options.