At Independent Health, we're proud to be Western New York's local health plan for more than 40 years. This year we want to give back to local organizations who are also dedicated to making a difference in our community. With your help, from October 1 – December 7, we will select 13 charities on a bi-weekly basis – awarding $650 to 65 total local charities. Please fill out the information below for the chance to support your favorite local charity. 
 
Please note: Information collected will only be used for the purpose of this nomination form and will not be shared with any other parties. 

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* 1. Full Name:

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* 2. Phone Number: 

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* 3. Charity You Are Nominating: 

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