1. Are you uninsured or underinsured? (required)
YesNo

2. Is this a temporary situation due to the economic crisis created by COVID? (required)
YesNo

3. Are you a healthcare worker? (required)
YesNo

4. Is your most recent employer a member of the Independent Physicians of the Carolinas? (required)
YesNo

Name (required)

Email (required)

Phone Number (required)

What is the name of your most recent employer? (required)

Date of Birth (required)

Dependents (Name & Date of Birth)

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