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MIAS FAMILY INSURANCE REGISTRATION

Because you should focus on your recovery, not your finances./ Enfocate en tu recuperacion, no en tus finanzas.

Type of service you are interested in./ Servicio de interes.

Service/ Servicio *
Zip Code and Filing Status/ Codigo postal y Estado civil en su declaracion de impuestos.

Zip code/ Codigo postal. *
Income Tax Filing Status*
Single/ Soltero (a)
Married Filing Jointly/ Casado (a) declarando juntos.
Married Filing Separately/ Casado (a) declarando separados.
Head of Household/ Cabeza de familia.
Qualifying widow( er )with dependant children./ Viudo (a) con ninos menores.
First  Name

First Name*

Middle Name

Last Name*

Phone*
First  Date of Birth*
First  Yearly Household Income ( Health Insurance)/ Ingresos anuales ( para seguro de salud).

Yearly Income *
First  Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Yearly Household Income ( Health Insurance)/ Ingresos anuales ( para seguro de salud).

Yearly Income *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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