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SHARE YOUR UNINSURED STORY
Sharing your story can make the difference! Please fill out the information below. IMCHC/Covering Kids and Families Illinois representative will follow-up with you within a week. CONTACT INFORMATION
*Name:
*City:
Email:
Home Phone:
Work Phone:
ext.
Cell Phone:
At least one phone number is needed. If you do not have a phone, please provide an alternative contact name and phone number where we may reach you at.
Alternative Contact Name:
Alternative Phone:
YOUR STORY Who in your family is uninsured? (Please list each member separated by a comma.) How long have you/they been uninsured? months years
What are the circumstances that surround(ed) being uninsured? (Limit 800 characters)
DEMOGRAPHICS Your age
Household Size (including yourself) 1 2 3 4 5 5 6 7 8 8+
Approximate annual household income size <20,000 20,001 - 39,999 40,000 - 79,000 >80,000
Race/Ethnicity White/Caucasian Asian/Pacific Islander Hispanic/Latino Black/African American Native American Other
PRESS & EVENTS Are you willing to share your story with the media or at an event? yes no
If you have any questions, please call Laura Leon at 312-491-8161 or you can email her at lleon@ilmaternal.org. Thank you for your time!
