Ahern Insurance Brokerage

Health Coverage Request

Primary
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Sex
How would you like to get information about this request?
Is this person applying for health care coverage?
(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship status is optional)
If you are a lawfully present non-citizen, enter the following information:
 
Include the document type, your “A” number and receipt number or other immigration number:
 
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Does anyone claim you as a dependent on their taxes?
Are you going to file taxes for the benefit year?
Expected tax filing status for the current year (select one)
 
RACE / ETHNICITY CODE (OPTIONAL – check all that apply) If American Indian or Alaska Native, do not enter a race or ethnicity
 
Do you receive Medicare benefits?