Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 12
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29Insurance 2:
Enrolled
Not Enrolled, but available
(Complete Attachment C)
Date Ended:
Name(s) of individual(s) covered:
Name of insurance company:
Phone #:
D34314000241229
Address of insurance company:
Group #:
Policyholder name:
Policy #:
Policyholder birth date:
Policyholder SS#:
If insurance is through an employer, list employer’s name and phone #:
Premium cost:
$
Date due:
How often:
Type of Insurance:
Medical
Limited
Start date:
Coverage:
Dental
Comprehensive
Is this a retiree health plan? .................
Yes
No
70. Does anyone in your household currently have Medicaid, CHIP or Medicare? If yes, check the type of coverage and
write the person(s) name(s) next to the coverage they have.
Medicaid: _________________________________________________________________________________
CHIP: ____________________________________________________________________________________
Medicare: _________________________________________________________________________________
71. Has anyone in your household been injured in an accident or been a victim of assault
in the last 12 months? ...........................................................................................................................
Yes
No
72. Is someone outside of your household required to pay for your household’s medical services? …….
Yes
No
73. Does anyone in your household have a major medical need? ..............................................................
Yes
No
(This includes pregnancy/cancer/kidney disease, etc. Answering this question may get you extra help.)
If yes, who? ___________________________ What is the medical need? ________________________________
74. Does anyone help you pay mortgage/rent, food, or utility bills? ……………………………………,,…..
Yes
No
75. Do you live with at least one child under the age of 19, and are you the main person taking
care of this child? ..................................................................................................................................
Yes
No
76. Has anyone in the household been in foster care at age 18 or older? ..................................................
Yes
No
If yes, who? _________________________________
77. Deductions: Check all that apply, provide the amount, who received it and how often it’s received. If you pay for certain
things that can be deducted on a federal income tax return, telling us about them could make the cost of health
coverage a little lower. Note: You should not include a cost that you already considered in your answer to net self-
employment (question 18).
Student loan interest:
$
Who?
How often?
Other deductions:
$
Who?
How often?
78. Other income: Check all that apply, give the amount and how often you get it.
How often?
Net farming/fishing:
$
Who?
How often?
Net rent/royalty:
$
Who?
79. Yearly Income: Complete only if your income changes from month to month. If you do not expect changes to your
monthly income, skip to the next question.
Total income THIS year:
$
Total income NEXT year:
$
80. What is your email address? ________________________________________________________________________
Page 12
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