2003 Application & Renewal Form (Page 2 of 6) in pdf

Section D: Other Household Members

We need information about others who live in the household and who are the parents, stepparents and spouses of the people who

want HUSKY health insurance. Include information about yourself if you are a parent in the home but did not list your name in section C because you do not want HUSKY for

yourself. Also, please list any other children in the household under age 19 who are not applying for HUSKY health insurance. Do not include anyone listed in Section B or C of

page one. Attach additional sheets if necessary.

Receives

Social Security

Show who this person is related to and how they

Name

Date of Birth

Earned

Other

)

Number (Optional)

are related (Example, father of Billy Smith

Income?

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

❑ Yes

❑ No

Section E: Parents Who Do Not Live in the Household

– If you are a parent or a caretaker living with a child and you want HUSKY coverage for yourself, you must

agree to cooperate with child support. This means that you will give us information about parents who do not live in the home and help us pursue medical support. If you do not

agree to cooperate you cannot get HUSKY for yourself: however, your children can still qualify for HUSKY

You may ask for an exemption from this requirement if you feel there

is a threat of domestic violence. Even if you do not want HUSKY for yourself we can help you obtain child support.

Do you agree to cooperate with the Child Support Division to seek medical support for your children from a parent who does not live in the home? ❑ ❑ ❑ ❑ Yes ❑ ❑ ❑ ❑ No.

If you do not want to cooperate, is the reason a fear of abuse by the parent who is not in the home? ❑ ❑ ❑ ❑ Yes ❑ ❑ ❑ ❑ No

Do you want us to help you obtain child support? ❑ ❑ ❑ ❑ Yes ❑ ❑ ❑ ❑ No.

If you agree to help us pursue support, please provide the following information. Also, if you are applying for your children who do not live with you, please provide the following

information.

Name of Parent

Name of Child

Parent’s Address

Name, Address, and Phone Number of Parent's Employer

Section F: Employment Income -

Complete the following for anyone in Sections C and D who receives earned income. Include your earnings if you are a parent of a

child listed in section C. Also, include your income if you are a caretaker relative and you want HUSKY for yourself. If a person has more than one job, list each job separately.

Full-time or part-

Is this self-

Hours

Pay Before

Name of Employed

time student?

Government

Date

employed

Employer Name, Address and Phone Number

Worked

Deductions

Person

Employee?

Started

If yes, name of

income?

per Week

(including tips)

school?

❑

City/Town

❑ Yes ❑ No

❑

State

per

❑

Federal

❑

City/Town

❑ Yes ❑ No

❑

State

per

❑

Federal

Section G: Other Income -

Please complete the following for anyone in Sections C and D who receives other income such as child support, Social Security, or

Unemployment Compensation. Include your unearned income if you are a parent of a child listed in Section C. Also include your unearned income if you are a caretaker relative

and you want HUSKY for yourself.

Name of Person

Type of Income

How Much?

How Often?

IF YOU HAVE ANY QUESTIONS ABOUT THIS APPLICATION OR NEED HELP COMPLETING IT, CALL 1-800-656-6684.

W-1HUS (Revised 4/2003)