HIICAP Volunteer Interest Form

Note: The HIICAP program does not allow individuals who are currently licensed as health insurance agents/brokers, or have some other conflict of interest, to counsel, administer, or volunteer for HIICAP in any capacity. Individuals in such cases will not be considered for volunteer roles.

First Name:

Last Name:

Email:

Telephone:

County:

Why are you interested in volunteering with the Health Insurance Information, Counseling and Assistance Program (HIICAP)?

Please check all the volunteer methods below that interest you.

Distribute information

Provide administrative support

Table at outreach events

Present to small and large groups

Provide Medicare/Insurance counseling

Other…

What experience, if any, have you had with Medicare and/or other health insurance/health-insurance-related programs?