Health Insurance Assistance Form

Health Insurance Assistance Form
No matter where you live in the U.S., we’re here to help.

Please complete this short online form and a Health Benefits Specialist will contact you by phone and/or email. Please note that due to a high volume of requests, it can take up to 2-4 business days to get back to you. We are working as quickly as we can and look forward to speaking with you soon!  Thank you.
What kind of assistance do you need? Please select all that apply.*

New enrollmentHelp with current planRenewal of Marketplace coverageRenewal of MediCal/Medicaid coverageGeneral InfoMedicare Counseling (for people 65+ or the differently abled)Friedman Health Center subsidy applicationOther
Please describe your current situation and how we may be of help:*
Who are you seeking insurance for?*

SelfSpouse or partnerOther dependentsNone
Spouse/Partner Name

First NameLast Name
Spouse/Partner Date of Birth

MonthDayYear
Date
Who else are you looking to insure? Names and dates of birth of dependents.
The demographic information requested below is confidential, collected for statistical and reporting purposes, and helps us to better understand the communities we serve.
First Name*
Middle Name
Last Name*
AKA
Birthday*

MonthDayYear
Date
Last 4 digits of SSN*
Street Address*
City*
State*
5 digit Zip*
Mobile*
Please note that this number may be used to contact you.
Other phone
Industry Relationship*
Email*
Gender*
Gender Self-Describe
Do you identify as transgender?*
Race/Ethnicity (select all that apply)*

European American/WhiteAfrican American/BlackLatino/HispanicAsianNative American or Alaskan NativeMiddle Eastern or Northern AfricanNative Hawaiian or Pacific IslanderPrefer to self-describePrefer to not respond
Race/Ethnicity Self-Describe
Marital Status*
Union Membership (select all that apply)*

Non unionWGAAEADGAAGVAIATSEAGMASAG-AFTRAAFMOther
Select WGA Location*

WGA-EastWGA-West
AFM Local #*
IATSE Local #*
How many arts/entertainment occupations do you have?*
Occupation 1*
Occupation 2*
Occupation 3*
Do you currently have insurance?*

YesNo
Does your insurance have an end date?

YesNo
Insurance End Date (if applicable)

MonthDayYear
Date
What is the source of your current coverage*

UnionCobraMarketplace/ExchangeMedicaid/Medi-CalOff-Marketplace/ExchangeMedicare or Medicare Advantage PlanSpouseParentEmployerNone
Total Annual Household Income*
Have you ever worked with a health insurance counselor at our organization?*
Please select a counselor
How did you hear about our insurance counseling service? Check all that apply

Actors Access AdBackstage AdSAG-AFTRA AdEntertainment Community Fund EmailSocial PostFlyerWorkshop/SeminarWord of mouthUnion health plan/RepresentativeOther Entertainment Community Fund programOther (Please specify below)
If you heard about our insurance counseling services elsewhere, please specify
I want to join the Entertainment Community Fund community for emails on services.
Worker Section
Please select the Counselor
Counselor Email
Client Email Response

AFL-CIO MedicareAging Into MedicareCalifornia/West Coast Default ResponseAHIRC East Coast ResponseGeneral Medicare QuestionsEHIS Redirect to George GeldinRedirect to Social Services Financial Assistance
Activity

InformationStarted enrollmentCompleted enrollmentIdentity ProofingCase consultation with internal departmentProblem ResolutionResearchContact with exchange/insureMedicare counselingFHC Subsidy
Assessment/ Result of Work
Type of Work/ Enrollment
Type of Coverage attained
Comments on this client (please include any information that will help the FA committee complete their assessment)
Worker Section Complete?
Date*

MonthDayYear
Date
Should be Empty:

Health Insurance Assistance Form

Worker Section