• 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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  • Basic Info

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  • Spouse Information

    Even if your spouse doesn't need coverage, we still need their information.
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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.
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  • Employer/Income Tax Information

  • 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.

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  • 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.
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