Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 7
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13N. MEDICAL INSURANCE – Complete if you are applying for Medical Assistance or Temporary Cash Assistance
1. Has anyone applying dropped health insurance coverage in the past six months? □ YES □ NO
2. Does anyone applying have any health insurance? □ YES □ NO If you answered yes to question 2, fill in the section
below.
HEALTH INSURANCE POLICY NUMBER 1
POLICY HOLDER NAME
POLICY NUMBER
GROUP NUMBER
HOUSEHOLD MEMBER(S)
RELATIONSHIP OF MEMBER TO
HOUSEHOLD MEMBER(S)
RELATIONSHIP OF MEMBER
COVERED BY POLICY
POLICY HOLDER
COVERED BY POLICY
TO POLICY HOLDER
POLICY HOLDER ADDRESS
Number
Street
City
State
Zip Code
Telephone
INSURANCE COMPANY/UNION
Insurance Company Name
Number
Street
City
State
Zip Code
Telephone
HEALTH INSURANCE POLICY NUMBER 2
POLICY HOLDER NAME
POLICY NUMBER
GROUP NUMBER
HOUSEHOLD MEMBER(S)
RELATIONSHIP OF MEMBER TO
HOUSEHOLD MEMBER(S)
RELATIONSHIP OF MEMBER
COVERED BY POLICY
POLICY HOLDER
COVERED BY POLICY
TO POLICY HOLDER
POLICY HOLDER ADDRESS
Number
Street
City
State
Zip Code
Telephone
INSURANCE COMPANY/UNION
Insurance Company Name
Number
Street
City
State
Zip Code
Telephone
0. LIFE INSURANCE, FUNERAL PLANS or BURIAL FUNDS – Complete if you are applying for Medical Assistance or
Temporary Cash Assistance
NAME OF PERSON
NAME OF PERSON
FACE VALUE
CASH
POLICY NUMBER
COMPANY, FUNERAL HOME OR
INSURED
WHO PAYS
OR VALUE OF
VALUE
OR ACCOUNT
BANK NAME
PLAN
NUMBER
PLEASE USE THIS SPACE IF YOU NEED TO GIVE US MORE INFORMATION ABOUT ANY APPLICATION QUESTION.
If you need more space, ask for the 9701- Application for Assistance Addendum.
DHR/FIA CARES 9701 Revised 9/09
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