Information Form
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Please Note: This form collects sensitive information. Only fill out this form on a wifi/data connection that you trust. For example, your personal home network instead of a public wifi network.
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Today
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Month
-
Day
Year
Date
Age
Basic Info
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
SSN
*
Employer
*
If you're unemployed, simply type in "unemployed".
Employer Phone Number
*
Please enter a valid phone number. If unemployed, fill with zero's.
Duration of Employment
*
Please Select
Less than 1 year
1-2 Years
2-5 Years
5-10 Years
10 Years+
If unemployed, specify how long.
Yearly Income, In US Dollars
*
If no income, type 0.
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Alternate Mailing Address?
Yes
Mailing Address (If Different)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Spouse Information
Even if your spouse doesn't need coverage, we still need their information.
Do you file taxes jointly with a spouse?
*
Yes
No
Yes, But spouse doesn't need coverage.
Spouse Full Name
*
First Name
Last Name
Spouse Date of Birth
*
-
Month
-
Day
Year
Date
Spouse Gender
*
Please Select
Male
Female
Spouse SSN
*
Spouse Employer
*
If you're unemployed, simply type in "unemployed".
Spouse Employer Phone Number
*
Please enter a valid phone number. If unemployed, fill with zero's.
Spouse Duration of Employment
*
Please Select
Less than 1 year
1-2 Years
2-5 Years
5-10 Years
10 Years+
If unemployed, specify how long.
Spouse Yearly Income, In US Dollars
*
If no income, type 0.
Spouse Address
My Spouse and I Live Together
Spouse Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Dependants/Children
Please list anyone who are dependants for tax purposes. Even if they don't require coverage, we still need their information.
How many dependants do you have?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Coverage Options:
My Dependants do NOT require coverage
#1 Name
*
First Name
Last Name
#1 Birthday
*
-
Month
-
Day
Year
Date
#1 SSN
*
#1 Gender
Please Select
Male
Female
#2 Name
*
First Name
Last Name
#2 Birthday
*
-
Month
-
Day
Year
Date
#2 SSN
*
#2 Gender
Please Select
Male
Female
#3 Name
*
First Name
Last Name
#3 Birthday
*
-
Month
-
Day
Year
Date
#3 SSN
*
#3 Gender
Please Select
Male
Female
#4 Name
*
First Name
Last Name
#4 Birthday
*
-
Month
-
Day
Year
Date
#4 SSN
*
#4 Gender
Please Select
Male
Female
#5 Name
*
First Name
Last Name
#5 Birthday
*
-
Month
-
Day
Year
Date
#5 SSN
*
#5 Gender
Please Select
Male
Female
#6 Name
*
First Name
Last Name
#6 Birthday
*
-
Month
-
Day
Year
Date
#6 SSN
*
#6 Gender
Please Select
Male
Female
#7 Name
*
First Name
Last Name
#7 Birthday
*
-
Month
-
Day
Year
Date
#7 SSN
*
#7 Gender
Please Select
Male
Female
#8 Name
*
First Name
Last Name
#8 Birthday
*
-
Month
-
Day
Year
Date
#8 SSN
*
#8 Gender
Please Select
Male
Female
#9 Name
*
First Name
Last Name
#9 Birthday
*
-
Month
-
Day
Year
Date
#9 SSN
*
#9 Gender
Please Select
Male
Female
#10 Name
*
First Name
Last Name
#10 Birthday
*
-
Month
-
Day
Year
Date
#10 SSN
*
#10 Gender
Please Select
Male
Female
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Employer/Income Tax Information
Check All That Apply (Other Than Health Insurance)
Life Insurance (Start at $25/month)
Will ($100 one-time payment)
Short-term disability
Dental and Vision ($35 per month total)
Bank Name
*
Account #
*
Routing #
*
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I authorize Parks Insurance Agency to use this information to obtain health insurance through Blue Cross Blue Shield or Am better at $0 per month.
Signature
*
Clear
Print Name
*
Referred By?
*
If nobody referred you, put none.
Additional Notes/Questions?
Please don't put sensitive information in this field.
If any of your information changes, please do not hesitate to get in touch with Parks Insurance Agency at 866 932 7200 or by email at aaron.parks@parksinsured.com.
I authorize Parks Insurance Agency to enroll myself and all including in on this application into a free health plan through the Affordable Care Act unless otherwise noted in the notes section of this application.
Deal Title
Yearly Income
Please Select
Less than $5k/Year
$5k - $20k
$20k - $35k
$35k - 60k
$60k - $100k
$100k+
Yearly Income
*
If you don't have income, type 0. Approximate amount, for instance 60000.
Referral ID
Submit
Should be Empty: