Health Benefits Affidavit

Health Benefits Affidavit
Please complete this affidavit to declare your eligibility and dependents for health benefits coverage.
Applicant's Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employment Status
Type of Health Benefits Requested
Other
List Your Dependents (if any)
Are any dependents covered by another health insurance plan?
If yes, please provide details of the other coverage (company name, policy number, covered individuals)
Signature of Applicant
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