• General ACA Questionaire

    By submitting this application, you represent that you have permission from all of the people whose information is on the application to submit their information to the Marketplace, and receive any communications about their eligibility.

  • New Clients Only

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  • If more than, pls put in additional information.

  • Please include a copy of your id.

  • By signing this this form, you agree to allow Chi Ching Financial to use this information to assist you in enrolling in a health insurance and/or dental insurance plan.