楊玫保險健保新客戶申請表

楊玫保險2021健保新客戶申請表

2021 HEALTHCARE NEW CLIENT APPLICATION
Name姓名 *

First Name 名 Last Name 姓
Phone Number電話 *

Number
Email電子郵件
example@example.com
Address地址 *

Street Address

Street Address Line 2

City State

Zip Code/邮编
主申請人信息 Applicant Information
2020年是否有健保？Do you have health insurance in 2020? *

有/Yes 没有/No
主申請人2021個人/家庭報稅單上有其他家庭成員嗎？Any other family members on the applicant's 2021 personal/family tax return report? *

有/Yes 沒有/No
* 請填寫家庭成員信息- (請列出家庭報稅表上的全部家庭成員,不需要申请健保的家庭成员也请提供姓名，性别，生日。请向右滑动屏幕填写所有问题). *

Family Members Information (Please include all the family members in your family annual tax report, for those members in tax report but no need health insurance can provide the personal information without visa type), please click the Add a new row beside for adding additional family members.
有家庭成員目前有Medicaid或Peachcare嗎？Does any family member(s) currently have Medicaid or Peachcare?

有/Yes 沒有/No
什麼時候被拒絕的？The date be rejected?

Month Day Year
日期/Date
*公民或持有綠卡五年以上的19歲以下孩子，如果最近沒有被Medicaid/PeachCare拒絕過，健保中心根據家庭收入狀況，有可能將孩子的申請自動送入GA Medicaid/PeachCare Program.

Children under the age of 19 who are citizen or have held a green card for more than five years, if they have not been rejected by Medicaid/PeachCare recently, the health insurance center may automatically send the child's application to the GA Medicaid/PeachCare Program based on family income level.
請上傳移民身份證明文件 Please upload the immigration identification documents below

點擊這裡上傳文件 (Click here to Upload Document)

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其他內容及說明Additional Comments or Questions
请签名：我確認以上我提供的資料全部屬實，我選擇的經紀人無需對我提供的資料負責。Please sign: I confirm that the above information I have provided is true and correct. The agent I selected is not responsible for the information I provided.

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楊玫保險2021健保新客戶申請表