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Insurance
Social Security Benefits
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Instagram WhatsApp YouTube Google Reviews Share Get Consultation

PARS FINANCIALS

We Don't Sell, We Buy Trust!

پارسی

Get Info

Tax Services
Business Structure
Insurance
Social Security Benefits
Resources

Elementor #856

Leave a Comment / Uncategorized / By admin

- Step 1 of 6

Are You Applying for Health Insurance Alone or Also for Other Member(s) of Your Household? *

Only Myself
Other Member(s)
Myself and Other Member(s)

How Many Other Member(s) Are Applying for Health Insurance? *

How Many Member(s) Besides You Are Applying for Health Insurance? *

Your Name: *

First

Last

Name of Member #1 Applying: *

First

Last

Name of Member #2 Applying: *

First

Last

Name of Member #3 Applying: *

First

Last

Name of Member #4 Applying: *

First

Last

Name of Member #5 Applying: *

First

Last

Name of Member #6 Applying: *

First

Last

Name of Member #7 Applying: *

First

Last

Email: *

Telephone Number: *

Physical Address: Street Address, (Apt/Unit #), City, State, and Zip Code: *

Address Line 1

Address Line 2

City

State

Zip Code

Is Your Mailing Address the Same as Your Physical Street Address? *

Yes
No

Mailing Address: Street Address, (Apt/Unit #), City, State, and Zip Code: (copy) *

Address Line 1

Address Line 2

City

State

Zip Code

Your Gender: *

Male
Female

Select Any that Applies to You: *

None
Tobacco user
Parent of child under 19
Pregnant

Are You Married? *

Yes
No

Your Spouse's Name *

First

Last

Would You Like to See If You Qualify for Financial Assistance (Subsidy) to Pay Your Health Insurance Cost? *

Yes
No

Are You or Any Member(s) in Your Household OFFERED Health Insurance through Their Employer? *

Yes
No

-->Note: If You or Anyone in Your Household is Offered Health Insurance through their Emoloyer, Like a Parent or Spouse, You or the Member(s) Applying May Not Be Eligible for Financial Assistance to Pay the Insurance Premium.

But Generally, There Are Exceptions, Such As

If You Cannnot Enroll in Your Employer Plan Because You Have to Wait for The Enrollment Period to Open Up.
If the CHEAPEST PLAN Offered by Your Employer Costs More Than 9.12 Percent of Your Total Household Income. As Such, Your Employer Coverage Would be Deemed Unaffordable.

You Can Still Continue this Form and We Help You Determine If You Qualify for Financial Assitance.

Is Anyone Who Wants to Apply for Financial Assistance to Pay their Plan is Enrolled in OR is Eligible for Medicaid, Medi-Cal, Medicare, or TRI Care? *

Yes
No

-->Note: If Anyone Who Wants to Apply for Financial Assistance to Pay their Plan Premium Premium is Enrolled in OR is Eligible for Medicaid, Medi-Cal, Medicare, or TRI Care? they May Not Be Eligible for Financial Assistance to Pay the Insurance Premium.

You Can Still Continue this Form and We Help You Determine If You Qualify for Financial Assitance.

Are You a US Citizen or National? *

Yes
No

Are You or the Member(s) Applying a US Citizen or National? *

Yes
No

Is the Member(s) who Is Applying a US Citizen or National? *

Yes
No

Does Any of the Following Immigration Status Apply to You or other Member(s) Who Are Applying for Coverage? *

Does Any of the Following Immigration Status Apply to the Member(s) Who is Applying for Coverage? *

Does Any of the Following Immigration Status Apply to You? *

Please Upload Here the ID Card(s) or Immigration Document(s) Reflecting Your Immigration Status: *

Click or drag files to this area to upload. You can upload up to 22 files.

Please Upload Here the ID Card(s) or Immigration Document(s) For the Person(s) Applying for Health Insurance: *

Click or drag files to this area to upload. You can upload up to 22 files.

Your Estimated 2023 Household Annual Income: *

Enter the Total Estimated Annual Income that You Expect to Have from All Your Household Members. If You Are A W2 Employee, This Would be Your Pre-Tax Income. If You Are Self-Employed, This Would be Your Pre-Tax Net Profit.

Comment or Message on Any Thing Not Addressed on This Form

*By Submitting the Form Above, You Give Consent to Be Contact by Us.

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