Please enable JavaScript in your browser to complete this form.LayoutPRE-ENROLLMENT HEALTH INSURANCE FROM-COVERD CALIFORNIA Please print clearly or type to the best of your ability. FAX TO: 888-264-8995 or email to : info@1solutionca.comSection-1Section 1: APPLICANT INFORMATION - Tell us about yourselfPoint of Contact (Internal use)Section-1.1First name: *Last name: *Middle initial *Nationality Race *Section-1.2Social Security Number:Date of birth:GenderMaleFemalePrimary Language:Section-1.3Email:Home phone:Work phone:Cell phone: Section-1.4Mailing Address: City:State:Zip:Section-1.5Material status:SingleMarriedDevorceDomestic PartnerType of coverage requestedIndividualFamilyOtherSection ||: Tell us about the people who need health coverage. Include information about yourself -if you want health coverage.Person 1: Section 2.1.1Last Name:First Name (Middle Initial):U.S Citizen?YesNoRelationship to the ApplicantSocial Security:Earnings or Other IncomeYesNoDate of Birth:Gender M/FMFNationalityRaceHispanio Latino?YesNoPerson 2: Section 2.1.2Last Name:First Name (Middle Initial):U.S Citizen?YesNoRelationship to the Applicant:Social Security:Earnings or Other IncomeYesNoDate of Birth:Gender M/F:MFNationalityRace:Hispanio Latino?YesNoPerson 3: Section 2.1.3Last Name:First Name (Middle Initial):U.S Citizen?YesNoRelationship to the Applicant:Social Security:Earnings or Other Income:MFDate of Birth:Gender M/F:MFNationalityRace:Hispanio Latino?YesNoSection |||: Employee Income - Complete the following for anyone who receives earned income. Include your earnings; if you are a spouse or parent of a child listed above.Person 1: Section 3.1Name of Person Employed:Hour Worked per Week:Full/Part-Time Student?Weekly, Monthly, Annual Income:If Yes, Name of School..Is this Self Employed Income?Employeer Name:Date Started:Person 2: Section 3.2Name of Person Employed:Hour Worked per Week:Full/Part-Time Student?Weekly, Monthly, Annual Income:If Yes, Name of School.. Is this Self Employed Income?Employeer Name: Date Started:Person 3: Section 3.3Name of Person Employed:Hour Worked per Week:Full/Part-Time Student?Weekly, Monthly, Annual Income:If Yes, Name of School.. Is this Self Employed Income?Employeer Name: Date Started:I certify that I have this form or have had it read to me in a language that I understand and the information given is true and complete to the best of my ability knowledgeLayoutApplicant Signature:Clear SignatureDate:Organization Individual Reference:Certified Enrollment Entity - 1Solution 916-689-1978. Enrollment Office Location: CET - Center for Employment Training, 8376 Fruitridge Road, Sacramento, CA 95828Submit
