Individual Health Insurance Form

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Simply fill out Hamlin Clark Insurance's quick and hassle free health insurance application.
Click 'submit' and we will be in touch with you within 48 hours.

NOTE: All information submitted by prospective clients will be kept in strict confidence per the HIPPA regulations and all applicable insurance institution privacy laws.

Email *

First & Last Name *

Phone Number *

Date of Birth

SSN

Are you a Smoker?

Yes

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Are all individuals applying for coverage legal US Citizens/Residents?

Yes

Clear selection

Are any family members American Indian or Alaska Natives?

Yes

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Are you currently employed working over 30 hours per week?

Yes

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Are you eligible for group health coverage through your employer or spouse’s employer?

Yes

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If married, do you file your taxes jointly with your spouse?

Yes

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Please enter your approx 2020 Adjusted Gross Income (AGI) for entire household:

If your income this year will be higher/lower than your 2019 AGI please detail that here:

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