2003 Application & Renewal Form

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Application & Renewal Form
(W-1HUS, Revised 4/2003)
This application is for families who only need health insurance.
If you need other types of assistance for your family, call INFOLINE at 211. Deaf and hearing-
impaired individuals may use a TDD/TTY by calling 1-800-410-1681. Questions, concerns, complaints, or requests for information in
alternative
formats must be directed to
1-800-842-1508.
If you have any questions about this application or need help completing it, call 1-800-656-6684.
If the information you have does not fit on this form, please
attach separate sheets of paper as needed.
Section A: I want health insurance for: (Check (    ) the category or categories that match your situation.)
❑ Myself, my spouse (or other parent of my children) and our children under
❑ Myself only, I am pregnant. The date that my baby is due is
age 19 who live with us.
______________________________.
❑ Myself, and children in my care who live with me.
❑ My children under age 19 who do not live with me. I am under a court
❑ Only for the children in my care who live with me. I do not want health
order to provide medical support. This is the address of my children
insurance for myself.
_____________________________________________________________
❑ Myself only, I am under age 19.
Section B: Applicant Information - Tell us about yourself
Client ID
Last Name
First Name
MI
Maiden Name
Day Phone Number
Evening Phone Number
Street Address
City
State
Zip Code
Date of Birth
Gender
Mailing Address (If different)
❑ Male ❑ Female
Are You a US Citizen?
What Language Do You Speak
Are you Hispanic
Race–(Check all that apply)
Social Security Number (Optional if
(Optional if not applying for
Best?
not applying for yourself)
or Latino?
❑ Alaskan Native/Eskimo ❑ Asian ❑ Black or African descent
yourself)
❑ Yes ❑ No
❑ Native American
❑ Pacific Islander
❑ White
❑ Yes ❑ No
Section C: Tell us about the people who need HUSKY health care. Include information about yourself if you want HUSKY coverage.
Race
Is this person a
First Name
Relation-
Social
US Citizen?
Has Earnings
(select
Date of
parent of at least
Gender
Hispanic or
Last Name
and
ship to the
Security
If No, fill out
or other
from the
one of the
M/F
Birth
Latino?
above
J
?
Middle Initial
applicant
Number
Section
Income
?
children
categories)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
If anyone listed in this section is pregnant, please list their name and the date that the baby is due
__________________________________________.

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