Application For Hoosier Healthwise Page 2
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4APPLICATION FOR HOOSIER HEALTHWISE
FOR CHILDREN AND PREGNANT WOMEN
*DFRHHEE02*
State form 43202 (R8 / 8-12) / FI 2030
10. Are any applicants covered by health insurance now?
If yes, who?
Yes
No
______________________________
11. Did any applicants who do not have health insurance lose their coverage in the past 3 months? Yes No
If yes, who: ___________________________________________ When did coverage end?____________________
Please tell us why coverage was lost by putting a
beside the reason(s).
Loss of employment
Coverage limit reached
Non-custodial parent dropped insurance
Divorce
Could not afford
Company ended coverage
Other Specify: ___________________
12. Tell us how much work income you and other members of your family make.
Name of person working _________________________________
Name of person working _______________________________
Start Date: _________________ End Date: ________________
Start Date: ________________ End Date: ________________
How often Paid?
How often Paid?
Weekly
Bi/weekly
Monthly
Twice a Month
Weekly
Bi/weekly
Monthly
Twice a Month
Amount of Gross Pay Per Pay Period: $__________________
Amount of Gross Pay Per Period: $__________________
Hours worked a week: ____ Do hours vary?
Yes
No
Hours worked a week: ____ Do hours vary?
Yes
No
Is person self-employed?
Yes
No
Is person self-employed?
Yes
No
Employer name and phone number
Employer name and phone number
13. Tell us if you or any family members receive other income from the types listed here. If your family has no
income, initial here _______. (For child support, put the child as the person receiving it)
1. SSI
6. Military Allotment
11. Interest Payments
2. Social Security
7. Unemployment
12. Educational Income
3. Veteran’s Benefits
8. Support (alimony or child support)
13. Cash from Friends, Relatives, etc.
4. Railroad Retirement
9. Sick Benefits
14. Worker’s Compensation
5. Pension
10. Strike Benefits
15. Other? Please specify ______________
Name of the Person Receiving the
What Type
How Often are
When did Payments
Amount of the
Payments
(from above)
Payments Received
Begin
Payments
If no, please explain:
14. Was the household income in the prior 3 months the same as it is now?
Yes
No
_______________________________________________________________________________________
15. Please read the following statement and sign your application below.
I certify under penalty of perjury, that all of the information I have provided is complete and correct to the best of my
knowledge and belief and that I have received the notice entitled “Important Information about Hoosier Healthwise” and
understand what it states.
Your Signature: ____________________________________________________________Date: _______________
Signature of witness if signed with “X”:_______________________________________________________________________
16. Do you want to register to vote? Yes No
Your answer will not affect your eligibility for health coverage.
DFRHHEE02
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