Health Insurance Enrollment Assistance Form for New York City Residents Survey

1.First Name:(Required.)

2.Last Name:(Required.)

3.ZIP Code:(Required.)

4.Age:(Required.)

I am 64 or younger

I am 65 or older

5.Disability status:

I am living with a disability

I am visually impaired

6.Type of service:(Required.)

I would like to enroll in health insurance

I would like to renew my current health insurance

I want information on health insurance only

7.Phone Number (XXX-XXX-XXXX)(Required.)

8.Best time to reach you:(Required.)

Morning

Afternoon

9.Preferred language (if other than English):