健保申請 (Affordable Care Act) 請您花幾分鐘的時間填寫下面的表格,這些信息將被嚴格保密,並僅用於您的健保申請 (Please take a moment to fill out the form below, this information will be kept confidential and will be used for health insurance application only). General InformationName (姓名):* Address (地址):* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (電話):*Email (電子郵箱): * 家庭成員信息- (請列出報稅表上的所有家庭成員,包括申請人,配偶,子女,父母[如果聯合一起報稅的話]. *請點擊下面表格右方的"+"來增加家庭成員數量/Family Members Information (Please including all the family members in the annual tax report), please click the "+" on the right for adding family members.姓名&與申請人關係 Name & Relationship性別 Sex生日 DOB 月 / 日 / 年 mm/dd/yy移民簽證類型及號碼 Visa Type工作公司名稱&電話 Employer Name & Telephone#預估2018年收入 Income Estimate of 2018是否申請健保? Apply or Not? 請點擊下面的上傳文件按鈕”Select Files”, 將您家人的社安卡,移民簽證文件(如:綠卡,公民紙,或工作簽證等)上傳給我們.如不方便, 您也可以隨後將這些文件微信/短信至770-268-1568, 或Email 至: info@amyins.com. 以便我們完成您及家人的健保申請./ Please click the upload attachments link “Select Files” below to send us a copy of your SSN and Visa, you also can email us at info@amyins.com, or WeChat/Texting us at 770-268-1568. Drop files here or Additional Comments or Questions (其他內容&問題):Electronic Signature (電子簽名):* 我確認以上我所提供的資料全部屬實,我選擇的經紀人無需對以上我所提供的資料負責。I confirm that the above information I have provided is true and correct. The agent I selected is not responsible for the information I provided.* I Agree (我同意) CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.