Contact | Every Color Matters

EVERY COLOR MATTERS BENEFIT

Please answer the set of questions below, in written form or via a recorded video, no longer than five (5) minutes and submit to ecmbenefit@gmail.com

Are you submitting on behalf of self or someone else?

Full Name

Email Address

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Type of cancer? How long have you had cancer? When were you diagnosed? Explain the phone call or day when you were diagnosed

Do you have children? If so, how many? Are you currently working? if not, how long have you been unemployed?

What type of treatment are you taking? How often do you take treatment?Do you have to travel for treatment? If so, how far?

Have you had any cancer related procedures?

Do you have a caregiver? If so, please provide his/her name

Do you currently have health coverage/insurance?

Do you currently have any special needs? (i.e. islolation requirements, dietary restrictions, transportation needs)

Greetings, Your application has been received and forwarded to our ECM Benefit Committee for processing. Please allow 15 days for review. You will receive a confirmation email outlining additional details and next steps once the application has been processed. Have a great day. Sincerely, ECM Benefits Team Admin