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). Contact Information姓名 Name First Last 性別 Sex生日(月 / 日 / 年) DOB(mm/dd/yy) Date Format: MM slash DD slash YYYY 移民簽證類型及號碼 Visa Type工作公司名稱&電話 Employer Name & Telephone #預估2021年全家收入 2021 Family Total Income Estimate預估主申请人自己2021年收入 Self Income Estimate of 2021抽烟吗? / Smoker?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- (請列出家庭報稅表上的全部家庭成員,不需要申请健保的家庭成员也需要提供个人信息但可以不提供移民签证信息). *填写/增加家庭成員，請點擊表格旁边的 /Family Members Information (Please include all the family members in your family annual tax report, for those members in tax report but no need health insurance can provide the personal information without visa type), please click the beside for adding additional family members.姓名 Name家庭关系 Relationship to main applicant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2021年收入 Income Estimate of 2021抽烟吗? / Smoker?是否申請健保? Apply or Not? Does the child currently have Medicaid or Peachcare?Has the child been rejected with Medicaid or Peachcare in last 3 months?請您點擊下面的上傳文件按鈕"Select Files", 將申请健保的家庭成员的社安卡,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 SSN and Visa for those members applying for health coverage, you also can email us at info@amyins.com. 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) PhoneThis field is for validation purposes and should be left unchanged.