Health Coverage Request

Primary

First Name

Last name

Date of Birth +

Address

State

Zip

Mailing address (If different)

Sex

FEMALE

MALE

Contact Number

(Secondary) Contact Number

Email

How would you like to get information about this Request?

Phone	Email
USPS Mail

Is this person applying for health care coverage?

Yes	No If no, SSN information is optional.

Social Security number

(For individuals not applying for coverage, providing a Social Security number (SSN) or citizenship status is optional)

U.S. citizen or U.S. national	Non-citizen lawfully present in the U.S.
Other

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:

Immigration document type:

“A” number:

Receipt number or other number:

Foreign passport number:

Country of issuance:

Date of entry: +

Document expiry date: +

Does anyone claim you as a dependent on their taxes?

Yes

No

Are you going to file taxes for the benefit year?

Yes

No

Expected tax filing status for the current year (select one)

Single filing taxes	Head of household
Qualifying widow(er) with dependent child	Married filing separately
Tax dependent of someone on the application	Tax dependent of someone not on the application
Person has neither filed taxes nor was tax dependent	Married filing jointly: Name of primary tax filer: Married filing jointly: Name of primary tax filer:

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?

Yes

No