健康保險估價 Health Insurance Quote

名 First name

姓 Last name

您是如何得知我們的？How did you hear about us?

居住地址 Address

電話 Phone

性別 Gender

生日 Birthday

Month

Day

Year

居留身分 Residency

電郵 Email

微信 WeChat ID

選擇辦公室 Select Office

您偏好的溝通語言 Preferred Language

特殊申請事件 Qualifying Life Events

您報稅時的家庭成員總共有幾位？（含您本人））How many people are in your tax household, including yourself?

您是否想要將配偶或子女一起加入保險計劃？Do you want to include your spouse or children in the plan?

如果是的話，請提供他們的姓名、出生日期，性別。If yes, please provide their names, birthdates, and gender.

請問是否所有人都有社會安全號碼？Do all individuals have a Social Security Number (SSN)?

您今年預估的稅前家庭總收入是多少？What is your estimated total household income before taxes for this year?

您目前是否已經有健康保險？Do you currently have any health coverage?

您希望新保險從什麼時候開始生效？When do you want the new coverage to start?

請提供您偏好的醫生姓名和地址 Please provide the name and address of your preferred doctor.

請選擇指定的經紀或是客服人員 Please select a designated agent or customer service representative.

備註 Additional Notes