Health Insurance Intake Sheet

Health Insurance Intake Sheet
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
This form is secured with HIPPA compliant security for your protection
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Best Contact Number*
Please enter a valid phone number.
Marital Status*

UnmarriedMarriedSeparatedDivorcedWidowed
Spouse Name*

First NameLast Name
Spouse Date of Birth*

MonthDayYear
Date
Spouse Social Security Number*

Projected Yearly Family Income*
Current Plan*
Current Deductible*
Current Tax Credit (if applicable)
Monthly Premium*

Will you be adding dependents to your policy?*

YesNo
How Many?*

123456
Dependent 1 Name*

First NameLast Name
Dependent 1 Date of Birth*

MonthDayYear
Date
Dependent 1 Social Security Number*
Dependent 2 Name*

First NameLast Name
Dependent 2 Date of Birth*

MonthDayYear
Date
Dependent 2 Social Security Number*
Dependent 3 Name*

First NameLast Name
Dependent 3 Date of Birth*

MonthDayYear
Date
Dependent 3 Social Security Number*
Dependent 4 Name*

First NameLast Name
Dependent 4 Date of Birth*

MonthDayYear
Date
Dependent 4 Social Security Number*
Dependent 5 Name*

First NameLast Name
Dependent 5 Date of Birth*

MonthDayYear
Date
Dependent 5 Social Security Number*
Dependent 6 Name*

First NameLast Name
Dependent 6 Date of Birth*

MonthDayYear
Date
Dependent 6 Social Security Number*
Should be Empty: