HIA Health Application

Enter the health application info to securely store the answers in a document for processing.

Date*
MM slash DD slash YYYY
Application Status
Please don't touch this when filling out the form; this is just for use internally after the initial form is saved. Thank you!
Agent & Plan Info
Agent Name*
Plan Name*
Expected Premium*
Carrier*
Master General Agent / NPN*
Please select an option based on carrier and state:
Constantine Christoforakis, 17328248 = Everything EXCEPT for BCBSFL, Florida Healthcare Plans (FHCP), & Vantage LA
Francis Naimoli, 17415842 = ONLY BCBS FL & Florida Healthcare Plans (FHCP))
Mark MacFawn, 8997756 = ONLY Vantage LA
- Constantine Christoforakis 17328248
- Francis Naimoli 17415842
- Mark MacFawn 8997756
Applicant Info
Primary Applicant Information*
First Name Last Name Suffix
Applying for Coverage?*
Home Address*
Street Address Address Line 2 City State ZIP Code
County*
- Mailing address differs from home address.
Alternate Mailing Address
Street Address Address Line 2 City State ZIP Code
County*
Email Address*
Phone Number*
Contact Preference
Gender*
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Total Household Income*
Estimates are okay.
Annual Income (primary)*
Estimates are okay.
Income Source (primary)*
Employer Name (primary)*
Employer Phone Number (primary)*
Additional Sources of Income (primary)
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
How do you plan to file taxes for 2019?*
Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Born in the US?
- Yes
- No
Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Permanent Resident Card
Alien Number (A#) Card # (Optional)
Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Household Size*
Please tell us about all members of your household, including those that are not applying for coverage. Your household is defined as the people on the same tax return as you.
# Applying for Coverage*
Applicant #2*
First Name Last Name Suffix
Applicant #2 - Applying for Coverage?*
Application #2 - Gender*
Applicant #2 - Date of Birth*
MM slash DD slash YYYY
Applicant #2 - Social Security Number*
Applicant #2 - Annual Income*
Estimates are okay.
Applicant #2 - Income Source*
Applicant #2 - Employer Name*
Applicant #2 - Employer Phone Number*
Applicant #2 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #2 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #2 - Born in the US?
- Yes
- No
Applicant #2 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #2 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #2 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #2 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #2 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #2 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #2 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #2 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #2 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Applicant #3*
First Name Last Name Suffix
Applicant #3 - Applying for Coverage?*
Application #3 - Gender*
Applicant #3 - Date of Birth*
MM slash DD slash YYYY
Applicant #3 - Social Security Number*
Applicant #3 - Annual Income*
Estimates are okay.
Applicant #3 - Income Source*
Applicant #3 - Employer Name*
Applicant #3 - Employer Phone Number*
Applicant #3 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #3 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #3 - Born in the US?
- Yes
- No
Applicant #3 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #3 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #3 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #3 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #3 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #3 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #3 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #3 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #3 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Applicant #4*
First Name Last Name Suffix
Applicant #4 - Applying for Coverage?*
Application #4 - Gender*
Applicant #4 - Date of Birth*
MM slash DD slash YYYY
Applicant #4 - Social Security Number*
Applicant #4 - Annual Income*
Estimates are okay.
Applicant #4 - Income Source*
Applicant #4 - Employer Name*
Applicant #4 - Employer Phone Number*
Applicant #4 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #4 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #4 - Born in the US?
- Yes
- No
Applicant #4 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #4 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #4 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #4 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #4 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #4 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #4 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #4 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #4 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Applicant #5*
First Name Last Name Suffix
Applicant #5 - Applying for Coverage?*
Application #5 - Gender*
Applicant #5 - Date of Birth*
MM slash DD slash YYYY
Applicant #5 - Social Security Number*
Applicant #5 - Annual Income*
Estimates are okay.
Applicant #5 - Income Source*
Applicant #5 - Employer Name*
Applicant #5 - Employer Phone Number*
Applicant #5 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #5 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #5 - Born in the US?
- Yes
- No
Applicant #5 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #5 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #5 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #5 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #5 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #5 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #5 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #5 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #5 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Applicant #6*
First Name Last Name Suffix
Applicant #6 - Applying for Coverage?*
Application #6 - Gender*
Applicant #6 - Date of Birth*
MM slash DD slash YYYY
Applicant #6 - Social Security Number*
Applicant #6 - Annual Income*
Estimates are okay.
Applicant #6 - Income Source*
Applicant #6 - Employer Name*
Applicant #6 - Employer Phone Number*
Applicant #6 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #6 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #6 - Born in the US?
- Yes
- No
Applicant #6 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #6 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #6 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #6 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #6 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #6 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #6 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #6 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #6 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Applicant #7*
First Name Last Name Suffix
Applicant #7 - Applying for Coverage?*
Application #7 - Gender*
Applicant #7 - Date of Birth*
MM slash DD slash YYYY
Applicant #7 - Social Security Number*
Applicant #7 - Annual Income*
Estimates are okay.
Applicant #7 - Income Source*
Applicant #7 - Employer Name*
Applicant #7 - Employer Phone Number*
Applicant #7 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #7 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #7 - Born in the US?
- Yes
- No
Applicant #7 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #7 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #7 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #7 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #7 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #7 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #7 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #7 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #7 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Applicant #8*
First Name Last Name Suffix
Applicant #8 - Applying for Coverage?*
Application #8 - Gender*
Applicant #8 - Date of Birth*
MM slash DD slash YYYY
Applicant #8 - Social Security Number*
Applicant #8 - Annual Income*
Estimates are okay.
Applicant #8 - Income Source*
Applicant #8 - Employer Name*
Applicant #8 - Employer Phone Number*
Applicant #8 - Additional Sources of Income
If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.
Applicant #8 - Check all that apply:
- US Citizen
- Married
- Parent/Caretaker
- Tobacco User
- Full-time Student
- Eligible for insurance through an employer (including a family member's employer) or COBRA?
- Currently enrolled in an individual health plan (not from an employer)
- Currently enrolled in Medicare
Applicant #8 - Born in the US?
- Yes
- No
Applicant #8 - Do you have any of the following?
- Certification of Naturalization or Citizenship
- Permanent Resident Card
- Employment Authorization Card
- Certificate of Non-Immigrant F-1 or I-20 (for students)
- Machine Readable Immigrant Visa w/ Temporary I-551 language
- Temporary Stamp I-551 on Passport or I-94, I-94A
- Arrival/Departure Record onト94,I94A
- Arrival/Departure Record in Foreign Passport
Applicant #8 - Certification of Naturalization or Citizenship
Certificate Number Registration Number Full Exact Name Issue Date
Applicant #8 - Permanent Resident Card
Alien Number (A#) Card # (Optional)
Applicant #8 - Employment Authorization Card
Alien Number (A#) Card # (Optional) Expiration Date (Optional) Category Code (Optional)
Applicant #8 - Certificate of Non-Immigrant F-1 or I-20 (for students)
SEVIS ID #
Applicant #8 - Machine Readable Immigrant Visa w/ Temporary I-551 Language
Alien Number (A#) Passport # Country of Issuance
Applicant #8 - Temporary Stamp I-551 on Passport or I-94,I-94A
Alien Number (A#)
Applicant #8 - Arrival/Departure Record onト94,I94A
I-94 # SEVIS ID #
Applicant #8 - Arrival/Departure Record in Foreign Passport
I-94 # Passport # Expiration Date Country of Issuance SEVIS ID # (Optional)
Authorizations

1. No one applying for coverage is in jail.
2. I give permission to the federal marketplace to access my tax returns years for up to five years to verify my income for subsidy purposes. I can revoke this permission at anytime.
3. I will notify the insurer if anything on this application changes. I can do this through the federal marketplace. I understand a change could affect our eligibility for plans and subsidies.
4. I’m electronically signing this application, which means I’ve provided true answers to all of the questions to the best of my knowledge.
5. I authorize (Your Name) to submit and sign this application on my behalf.
Notes
Please add any notes or other additional information here.
Please add any notes or other additional information here.

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Certificate Number	Registration Number	Full Exact Name	Issue Date

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

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HIA Health Application

Agent & Plan Info

Applicant Info

Authorizations

Notes

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