Form 403 - Diamond State Health Plan - Application For Health Insurance Page 3
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42. EARNED INCOME: Tell us about your family’s earnings from paychecks, tips, self-employment, babysitting, in-home sales, odd jobs.
Amount Before Taxes/Deductions
Person Working
Student
Employer/Source of Earnings
How Often Paid/Received
Yes
No
Yes
No
Yes
No
3. OTHER INCOME: Tell us about any other income your family has like Social Security, SSI, child support, Veteran’s Benefits, Unemployment
Compensation, pension, roomer, or cash given to you.
Person Paid To
Source of Money
How Often Paid
Amount Before Deductions
4. DEPENDENT CARE COSTS: Tell us how much you pay someone to care for a child or incapacitated adult so that you can go to work, look for work,
or get training.
Name of Child or Adult
Monthly Amount Paid
Name of Child or Adult
Monthly Amount Paid
5. HEALTH INSURANCE INFORMATION: Tell us about any health insurance you have.
Name of Policy Holder
Name of Insurance
Who is Covered
Circle What is Covered
Policy Number
Doctor Hospital Lab Tests Xray
Doctor Hospital Lab Tests Xray
Name anyone who has had health insurance in the last 6 months: _________________________________________________________________
Circle what the insurance covered: Doctor, Hospital, Lab Tests, X-rays
When did the insurance stop? __________________ Why did the insurance stop? _______________________________________________________
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Parent category: Legal