Name:* Employer Name (if applicable): Phone:* Email:* Address:*
City, State:* Zip:* County:* DOB:* Gender:* MF Tobacco:* NY
Spouse: DOB: Gender: MF Tobacco: NY
Child 1: DOB: Gender: MF
Child 2: DOB: Gender: MF
Child 3: DOB: Gender: MF
Child 4: DOB: Gender: MF
Child 5: DOB: Gender: MF
Child 6: DOB: Gender: MF
Child 7: DOB: Gender: MF
Child 8: DOB: Gender: MF
Child 9: DOB: Gender: MF
Child 10: Gender: MF DOB:
Child 11: Gender: MF DOB:
Child 12: Gender: MF DOB:
I am also interested in quotes regarding: DentalVisionLife
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First Name Social Security Number Do you plan to file a federal income tax return NEXT YEAR? You can still apply for coverage even if you don't file a federal income tax return. YesNo a. Will you file jointly with a spouse?YesNo If yes, write name of spouse: If yes, provide Social Security Number of spouse: b. Will you claim any dependents on your tax return?YesNo If yes, list name(s) and Social Security Number(s) of dependents:
Name: SSN:
c. Will you be claimed as a dependent on someone's tax return?YesNo If yes, please list the name of the tax filer: How are you related to the tax filer?
Employer Name Employer Address City State Zip Code Employer Phone Number Wages/tips (before taxes) How much?
If self-employed, answer the following two questions: a. Type of work: b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? How much?
Employer Name Employer Address City State Zip Code Employer Phone Number Wages/tips (before taxes) How much? If self-employed, answer the following two questions: a. Type of work: b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? How much?
Fill in all that apply, and give the amount and how often you get it. NOTE:You don't need to tell us about income from child support, veteran's payments, or Supplemental Security Income (SSI). Unemployment How much? How often? Pension How much? How often? Social Security How much? How often? Retirement accounts How much? How often?
Fill in all that apply, and give the amount and how often you pay it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn't include child support that you pay, or a cost already considered in your answer to net self-employment. Alimony paid How much? How often? Student loan interest How much? How often? Your total income this year How much? Your total income next year (if you think it will be different) How much?
Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, like a parent or spouse, even if they don't accept the coverage. YesNo Is anyone enrolled in health coverage now? YesNo
Name of person enrolled in health coverage Type of coverage: Employer InsuranceCOBRAMedicaidCHIPMedicareTRICAREVA health care programPeace CorpsIndividual Coverage If it's employer insurance: Name of health insurance company: Policy/ID number If it's individual coverage Name of health insurance company: Policy/ID number