Ahern Insurance Brokerage

Health Coverage Request

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:
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?