Individual and Family Plan Intake Form
Qualifying Life Event Reason Selection
Qualifying Life Event Reason For Health Insurance Enrollment
*
Recently moved to the United States
Recently moved to a new state
Recently moved to a new zip code
Recently moved to a new county
Lost Employer Sponsored Coverage
Lost Medicaid or Medi-Cal
COBRA expired
Got Married
Got Divorced
Birth of a Child
Death in the family
Reached age 26
Gained citizenship
Became a permanent resident
Released from incarceration
Released from military active duty status
Primary subscriber transitioned to Medicare and dependents lost coverage as a result
Other
Individuals and or Family Members' Information
Primary Enrollee's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number or ITIN
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Primary Care Provider Full Name
Specialists if applicable (Full name and specialty; e.g. Dr. Amanda Tan - Ophthalmology)
US Citizen?
*
Yes
No
If not a US Citizen, does the primary enrollee have any of the following?
*
I-1551 or Green Card or Permanent Resident Card
I-94 or valid arrival or departure record
Student Visa
Work Visa
Visitor/B2 Visa
Other
Primary Enrollee Driver License or Government Issued ID Upload
*
Browse Files
Drag and drop files here
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How many people are there in the household? (For example: husband, wife, 2 children = 4)
*
Do you have any dependents?
*
Yes
No
If yes, how many? (Who is considered a dependent = someone you claim in your taxes) If none, put N/A
*
Applicant Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number or ITIN
*
Primary Care Provider or Pediatrician
Specialists
US Citizen?
*
Yes
No
Applicant Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number or ITIN
*
Primary Care Provider or Pediatrician
Specialists
US Citizen?
*
Yes
No
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number or ITIN
*
Primary Care Provider or Pediatrician
Specialists
US Citizen?
*
Yes
No
Applicant Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number or ITIN
*
Primary Care Provider or Pediatrician
Specialists
US Citizen?
*
Yes
No
How will you file your taxes?
*
Single
Head of household
Married Filing Jointly
Married Filing Separately
What is your projected household income for THIS year?
*
What is the break down of the projected income? For example: Husband - W2 - $60k/year - XYZ Company
*
What is your current health insurance coverage? (HMO, PPO, EPO, none)
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Source of your CURRENT health insurance coverage
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Tricare
VA
Employer Sponsored
Spouse
Medi-Cal or Medicaid
Marketplace or Covered California
Short Term Medical
Other
What are you looking for for your next health coverage? (e.g. PPO plan with access to (name the hospital) and Dr. (name of doctor)); e.g. HMO plan with mid to low deductible). Share anything.
*
Bundle, Signature, and Date
Any other insurance policies you are interested in.
*
Life Insurance
Travel Medical Insurance
Dental
Vision
Home
Renters
Commercial
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
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