G04i 2026

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The document provides instructions for completing a form required for income verification related to health insurance benefits from an employer, specifically for the PeachCare for Kids program. It outlines the necessary information to be filled out regarding family members' health insurance status, including details about existing coverage and policy information. The form must be submitted within 14 days to ensure health benefits for children, and it includes options for submission via fax, internet, or mail.

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Click ‘Get Form’ to open the g04i document in the editor.
Begin by entering your Family Account Number at the top of each page. This is essential for tracking your application.
Provide personal information for yourself and each family member. Indicate if they currently have private health insurance or had it in the past.
If anyone has other health insurance, answer 'Yes' to question 1 and complete questions 2 through 10. If 'No', simply sign and date the certification.
Fill in details for each child regarding their coverage, including first and last names, and check applicable services like Major Medical or Dental.
Complete all required fields, ensuring accuracy before signing and dating the certification at the end of the form.
Once completed, you can submit your form via fax, online through our platform, or by mail as instructed.

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