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 StatusPlease don't touch this when filling out the form; this is just for use internally after the initial form is saved. Thank you!Saved for ProcessingSubmitted to MarketplaceChecked by SupervisorIssuesAgent & Plan InfoAgent Name*Christoforakis, AthenaPena, DeniseReber, SamanthaOtherPlan Name*Expected Premium*Carrier*AlliantAmbetterAnthem/HealthkeepersBCBSCareFirst VAFlorida Healthcare Plans (FHCP)Florida HospitalKaiserMedicaMolinaOscarVantageOtherMaster General Agent / NPN*Please select an option based on carrier and state:Constantine Christoforakis, 17328248 = Everything EXCEPT for BCBSFL, Florida Healthcare Plans (FHCP), & Vantage LAFrancis Naimoli, 17415842 = ONLY BCBS FL & Florida Healthcare Plans (FHCP))Mark MacFawn, 8997756 = ONLY Vantage LA Constantine Christoforakis 17328248 Francis Naimoli 17415842 Mark MacFawn 8997756Applicant InfoPrimary Applicant Information* First Name Last Name Suffix Applying for Coverage?*YesNoHome Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County* Mailing address differs from home address.Alternate Mailing Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County*Email Address* Phone Number*Contact PreferenceMailEmailGender*MaleFemaleDate 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)*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesEmployer 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?*Single, Filing TaxesSingle, Claimed as DependantSingle, Not Filing TaxesMarried, Filing JointlyMarried, Filing SeparatelyCheck 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 MedicareBorn in the US? Yes NoDo 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 PassportCertification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Permanent Resident CardAlien Number (A#)Card # (Optional) Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS 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.12345678# Applying for Coverage*12345678Applicant #2* First Name Last Name Suffix Applicant #2 - Applying for Coverage?*YesNoApplication #2 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #2 - Employer Name*Applicant #2 - Employer Phone Number*Applicant #2 - Additional Sources of IncomeIf 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 MedicareApplicant #2 - Born in the US? Yes NoApplicant #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 PassportApplicant #2 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #2 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #2 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #2 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #2 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #2 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Applicant #3* First Name Last Name Suffix Applicant #3 - Applying for Coverage?*YesNoApplication #3 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #3 - Employer Name*Applicant #3 - Employer Phone Number*Applicant #3 - Additional Sources of IncomeIf 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 MedicareApplicant #3 - Born in the US? Yes NoApplicant #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 PassportApplicant #3 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #3 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #3 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #3 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #3 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #3 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Applicant #4* First Name Last Name Suffix Applicant #4 - Applying for Coverage?*YesNoApplication #4 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #4 - Employer Name*Applicant #4 - Employer Phone Number*Applicant #4 - Additional Sources of IncomeIf 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 MedicareApplicant #4 - Born in the US? Yes NoApplicant #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 PassportApplicant #4 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #4 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #4 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #4 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #4 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #4 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Applicant #5* First Name Last Name Suffix Applicant #5 - Applying for Coverage?*YesNoApplication #5 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #5 - Employer Name*Applicant #5 - Employer Phone Number*Applicant #5 - Additional Sources of IncomeIf 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 MedicareApplicant #5 - Born in the US? Yes NoApplicant #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 PassportApplicant #5 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #5 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #5 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #5 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #5 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #5 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Applicant #6* First Name Last Name Suffix Applicant #6 - Applying for Coverage?*YesNoApplication #6 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #6 - Employer Name*Applicant #6 - Employer Phone Number*Applicant #6 - Additional Sources of IncomeIf 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 MedicareApplicant #6 - Born in the US? Yes NoApplicant #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 PassportApplicant #6 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #6 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #6 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #6 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #6 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #6 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Applicant #7* First Name Last Name Suffix Applicant #7 - Applying for Coverage?*YesNoApplication #7 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #7 - Employer Name*Applicant #7 - Employer Phone Number*Applicant #7 - Additional Sources of IncomeIf 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 MedicareApplicant #7 - Born in the US? Yes NoApplicant #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 PassportApplicant #7 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #7 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #7 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #7 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #7 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #7 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Applicant #8* First Name Last Name Suffix Applicant #8 - Applying for Coverage?*YesNoApplication #8 - Gender*MaleFemaleApplicant #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*JobSelf EmployedSocial Security BenefitsRetirement BenefitsUnemployment BenefitsFarming and FishingCapital GainsAlimonyPension BenefitsInvestmentOtherMultiple SourcesApplicant #8 - Employer Name*Applicant #8 - Employer Phone Number*Applicant #8 - Additional Sources of IncomeIf 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 MedicareApplicant #8 - Born in the US? Yes NoApplicant #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 PassportApplicant #8 - Certification of Naturalization or CitizenshipCertificate NumberRegistration NumberFull Exact NameIssue Date Applicant #8 - Permanent Resident CardAlien Number (A#)Card # (Optional) Applicant #8 - Employment Authorization CardAlien 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 LanguageAlien Number (A#)Passport #Country of Issuance Applicant #8 - Temporary Stamp I-551 on Passport or I-94,I-94AAlien Number (A#) Applicant #8 - Arrival/Departure Record onト94,I94AI-94 #SEVIS ID # Applicant #8 - Arrival/Departure Record in Foreign PassportI-94 #Passport #Expiration DateCountry of IssuanceSEVIS ID # (Optional) Authorizations1. 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.NotesPlease add any notes or other additional information here.Please add any notes or other additional information here.ΔFree Health Insurance ComparisonCompare Quotes from Top Companies and Save HealthMedicare or call 800-985-9449 for free quotes