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NY Free Insurance Plan (Government Subsidized, none Medicaid)
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Email
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First Name
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Last Name
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Gender
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Date Of Birth (MM/DD/YYYY)
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Marital Status
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Green Card/US Citizen/Visa or others
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Social Security Number
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Green Card Number
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Green Card Expiration date (MM/DD/YYYY)
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Driver License#
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Driver License Expiration date (MM/DD/YYYY)
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Driver License of which state
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Contact Phone Number
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Company Name
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Business Address
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File Tax Amount? Household size?
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Occupation
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Contact Address
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Please email the following documents to
Team@safepolicies.com
(copy of passport, social security card, pay stub & driver license are needed for identity verificate) Green Card/I-551 • I-766 •I-94/ I-94A） • ORR (ORR UAC/R-1) • Passport • Visa with I-94 stamp • I-797 USCIS • I-589 USCIS Confirmation（A5）
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Broker Assignment Letter（經紀人委派信）I, ____________appoint Nelson Lai as my broker for NY State Of Health medical & dental insurance.我 _______________委託Nelson Lai 擔當我紐約州健康醫療和牙科保險的經紀人。
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Date (MM/DD/YYYY)
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Signature(Type your name)
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Family Member (Name/Date Of Birth/SSN/Gender/Relationship)
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Available Date and Time
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