Life Events Study

Full Name:

Phone:

Email:

Age:

Gender:

State:

No, I do not have health insurance

Yes, I have Medicare, Medicaid, and/or Tricare

Yes, I buy my own health insurance

Yes, I have health insurance through my employer

Yes, I have health insurance through the employer of my spouse

Yes, I have health insurance through the employer of my parent(s)

Other (please specify)