Free Insurance Help Request

Free Insurance Help Request

*Fill out this form ONLY if you lost your health insurance due to involuntary job loss or hours reduction (ie layoff, furlough, or cut hours) AND are under age 65 (if you quit the job or are eligible for MediCARE you aren't eligible for this free insurance, if you are 65+ and in UNITE HERE Health visit www.uhh.org for info on special option)
Name*

First NameLast Name
Phone Number
By providing my phone number, I am opting to receive recurring text messages from UNITE HERE and that standard message & data rates may apply. I understand that I can unsubscribe at any time.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What company do you work for?*
What's your city/chapter?*
Did you lose your health insurance coverage due to involuntary job loss or hours reduction (ie layoff, furlough or cut hours)?*

YESNO
Are you eligible for another group health plan (ie through spouse/2nd job) or for Medicare?*

YESNONOT SURE
Have you received any paperwork in the mail from your health plan or from your employer regarding Free COBRA?*

YESNONOT SURE
If you have gotten something in the mail from your health plan/employer, upload a pic of it here if you can:

Cancelof
Any other questions?
Should be Empty: