HEALTH INSURANCE INTAKE FORM

HEALTH INSURANCE

Our team is here to help find the best health insurance plan for you, your family, and your budget. Let us save you time and effort by searching through plans from nationally and locally recognized companies on your behalf.
Primary Insured Name

First NameMiddle NameLast Name
Gender*

MaleFemale
Social Security Number*
Date of Birth*

MonthDayYear
Patient Status*

SingleMarriedOther
Address*

Street Address

CityState

Zip Code
E-mail*
example@example.com
Phone Number*
Immigration's Status*

CitizenTemporary StatusPermanent ResidentParole
Income Type*

JobSelf-employmentUnemploymentOther income
Company Name*
Select your ACA provider
Yearly income*
Other applicants to be covered - Partner or Children.

(IF APPLICABLE)
File Upload

Cancelof
I Authorize Legacy Faith Multi-Services to Process my application to the Marketplace for Health Insurance.
Sign*

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Date

MonthDayYear
Date
Referral Agent Name
Should be Empty:

HEALTH INSURANCE