加州全保身份信息更新表
CCA Personal Identification information Update
名字 Name
*
名 First Name
姓 Last Name
加州全保賬戶 CCA Account (選填 Optional)
郵箱 E-mail
*
電話 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
如果您符合以下情況之一， 請上傳相應文件 If you fall into any of the following categories, please upload the document(s):
*
已有綠卡或是美國公民 Green Card or U.S. citizen
已有工卡(EAD)或其他身份 Employment Authorization Document (EAD) or other immigration status documents
已收到綠卡/工卡延期信或批准信 Green Card/EAD extension notice or approval notice
舊身份已過期且暫無有效移民身份文件 Immigration status has expired, and currently do not have any valid immigration status documents
其他
*
請上傳
所有家庭成員
的身份文件。
*Please Upload document(s) for
ALL FAMILY MEMBERS
.
請上傳身份文件正面 Please upload front side of documents.
*
Browse Files
將文件拖放到這裏
挑選一個文檔
Cancel
of
請上傳身份文件反面 Please upload back side of documents.
*
Browse Files
將文件拖放到這裏
挑選一個文檔
Cancel
of
請上傳文件 Please upload the documents.
*
Browse Files
將文件拖放到這裏
挑選一個文檔
Cancel
of
其他説明 (Additional Comments if needed)
Back
Next
Save
簽字客戶名字 Client Name
*
手寫簽名 Signature
*
簽名日期 Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
移民身份文件收集聲明 (Immigration Document Collection Disclaimer)：
*
為協助您申請或維持 Covered California 保費補助資格，我們可能需要向您索取相關移民身份或合法居留證明文件，並代為上傳或提交至 Covered California 或相關政府機構進行資格驗證。您所提供的文件僅用於協助辦理健康保險申請、資格審核及補助申請相關事宜。我們不會將您的個人資料或移民身份資訊用於上述目的以外的用途，亦不會在未經您授權或法律要求的情況下向第三方披露。客戶須確保所提供文件及資訊真實、完整且有效。最終資格認定、補助核准與否，以及補助金額均由 Covered California 及相關政府機構依其規定審核決定，本公司僅提供協助服務，無法保證申請結果或補助資格。提交文件即表示您同意本公司協助您向 Covered California 或相關機構提交上述資料，以完成資格驗證及保險申請程序。To assist you in applying for or maintaining eligibility for Covered California premium tax credits and other health coverage assistance programs, we may request documentation verifying your immigration or lawful presence status and may submit such documentation to Covered California or applicable government agencies on your behalf for eligibility verification purposes.Any documents and information provided by you will be used solely for health insurance application, eligibility determination, and subsidy verification purposes. We will not use or disclose your information for any other purpose except as authorized by you or required by law.You are responsible for ensuring that all information and documents provided are accurate, complete, and current. Eligibility determinations, approval of financial assistance, and subsidy amounts are made solely by Covered California and applicable government agencies based on their rules and review process. Our agency provides assistance only and does not guarantee eligibility, approval, or any specific subsidy amount.By providing these documents, you authorize us to assist in submitting the information to Covered California and/or the appropriate government agencies for eligibility verification and health insurance enrollment purposes.
Save
提交 Submit
提交 Submit
Should be Empty: