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Health Care Application 健康保險申請
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* Indicates required question
Email
*
Your email
First Name 名字
*
Your answer
Last Name 姓氏
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Your answer
Email 電子郵箱
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Your answer
Phone 電話號碼
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Your answer
Date of birth 生日
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MM
/
DD
/
YYYY
Address 地址
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Your answer
City 城
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Your answer
Zip Code 郵編
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Your answer
Name of employer 工作地方的名稱
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Your answer
Income per year 一年收入多少?
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Your answer
Income per year 一年收入多少?
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Your answer
How many yrs in US 來美國多少年?
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Your answer
Family Member 1 家庭成員(配偶或18歲以下）
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Your answer
Family Member 2 家庭成員(18歲以下）
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Your answer
Family Member 3 家庭成員(18歲以下）
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Your answer
Family Member 4 家庭成員(18歲以下）
*
Your answer
Family Member 5 家庭成員(18歲以下）
*
Your answer
Are you plan to change plans? 是否要換保險計劃?
*
Yes 是
No 不是
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