Health-Gen Gold HMO
Coverage Start Date: 01/01/2017
You Pay: $300
Members Included: Sara Taylor, Smith Taylor, Nick Taylor, Linda Taylor
Applicant Information
First Name:
Sara
MI:
Last Name:
Taylor
Date of Birth:
10/10/1970
Gender:
Female
Tobacco User:
No
SSN:
***-**-8876
Primary Address
Address 1:
123 Taylor Mansion,
Address 2:
Harbor Street Road,
City:
Harbour View
County:
Maricopa
State:
Arizona
Zip Code:
85201
Dependent Information
Spouse
First Name:
Smith
MI:
Last Name:
Taylor
Date of Birth:
10/10/1970
Gender:
Male
Tobacco User:
No
SSN:
***-**-8765
Address same as Primary Applicant
Child 1
First Name:
Nick
MI:
Last Name:
Taylor
Date of Birth:
12/01/2000
Gender:
Male
Tobacco User:
No
SSN:
***-**-9015
Address same as Primary Applicant
Child 2
First Name:
Linda
MI:
Last Name:
Taylor
Date of Birth:
10/11/2004
Gender:
Female
Tobacco User:
No
SSN:
***-**-9821
Address same as Primary Applicant
PCP Information
Sara Taylor:
Thompson, Robert, MD
Smith Taylor:
Thompson, Robert, MD
Nick Taylor:
Thompson, Robert, MD
Linda Taylor:
Thompson, Robert, MD
Acknoweldgement
You agreed to the T&C as of 09/12/2016
Health-Gen Advanced Dental
Coverage Start Date: 01/01/2017
You Pay: $50
Members Included: Sara Taylor, Smith Taylor
Applicant Information
First Name:
Sara
MI:
Last Name:
Taylor
Date of Birth:
10/10/1970
Gender:
Female
Tobacco User:
No
SSN:
***-**-8876
Primary Address
Address 1:
123 Taylor Mansion,
Address 2:
Harbor Street Road,
City:
Harbour View
County:
Maricopa
State:
Arizona
Zip Code:
85201
Dependent Information
Spouse
First Name:
Smith
MI:
Last Name:
Taylor
Date of Birth:
10/10/1970
Gender:
Male
Tobacco User:
No
SSN:
***-**-8765
Address same as Primary Applicant
Coverage Start Date: 01/01/2017
You Pay: $50
Members Included: Bruce Taylor
Applicant Information
First Name:
Bruce
MI:
Last Name:
Taylor
Date of Birth:
10/10/1940
Gender:
Male
Tobacco User:
No
SSN:
***-**-3012
Primary Address
Address 1:
123 Taylor Mansion,
Address 2:
Harbor Street Road,
City:
Harbour View
County:
Maricopa
State:
Arizona
Zip Code:
85201
PCP Information
Bruce Taylor:
Thompson, Robert, MD
Acknoweldgement
You agreed to the T&C as of 09/12/2016
Advanced Drug Care
Coverage Start Date: 01/01/2017
You Pay: $50
Members Included: Bruce Taylor
Applicant Information
First Name:
Bruce
MI:
Last Name:
Taylor
Date of Birth:
10/10/1940
Gender:
Male
Tobacco User:
No
SSN:
***-**-3012
Primary Address
Address 1:
123 Taylor Mansion,
Address 2:
Harbor Street Road,
City:
Harbour View
County:
Maricopa
State:
Arizona
Zip Code:
85201
PCP Information
Bruce Taylor:
Thompson, Robert, MD
Acknoweldgement
You agreed to the T&C as of 09/12/2016
