Health Insurance Application

SOUTHERN LEGACY PARTNERS

Health Insurance Application
Please note that we are currently outside of the Open Enrollment period. In order to enroll in a policy at this time, you must have a qualifying life event that meets eligibility requirements.
First Name*
Last Name*
DOB*

MonthDayYear
Date of Birth
Email *
example@example.com
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Communication
MaleFemale
SSN *
Social Security Number
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address( If different from residential address )

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name & Phone Number

namePhone Number
What Doctor/Provider do you want your insurance to cover?
What medications do you want your insurance to cover?
Marital Status ( According to your taxes)*
YesNo
Please provide Name and Date of Birth of Spouse
If Spouse needs insurance also, Please provide Social Security Number.
Are you claiming any Dependents on your taxes?*
Must include on the application if they are on the tax return, but we do not have to select them as needing coverage.
YesNo
Please provide Name and Date of Birth of dependents.
If the dependents need insurance as well, please provide their social security number.
YesNoAlien Number/ USCIS #/ Card #
Occupation/Job Title
Annual Adjusted Gross Income
YesNo
Do you have health insurance currently?
Are you currently on Medicaid, Medicare, SSI, Disability, etc.?
Change in household( Marriage, divorce, birth/adoption, or death in immediate family)Realeased from incarcerationLost health coverage( job-based, individual, student, Medicare, Medicaid, CHIP, or turning 26 off family plan)Became a U.S. citizen or lawful residentGained tribal membership/ Alaska Native shareholder statusStarted or ended AmeriCorps serviceChanged residenceNone of these
Please provide the following information, as applicable:
If you have recently relocated, include your previous ZIP code.If you have been released from incarceration, provide your release date.For all other situations, provide the date of the occurrence.
Consumer Consent

I give permission to Southern Legacy Partners to serve as the health insurance agent for myself and my entire household if applicable, for enrollment in a Qualified Health Plan offered on the Georgia State-based Exchange (Georgia Access). By consenting to this agreement, I authorize the above-mentioned agent/agency to view and use the confidential information provided by me in writing, electronically, or by telephone.
Signature*

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SOUTHERN LEGACY PARTNERS

Consumer Consent