Request for Assistance

Please make sure you have the following information available before filling out this form:

1. Employee information
2. Summary of event with documentation
3. Insurance information
4. Event expenses information and documentation
5. Employee income information

Step 1 of 5: Employee Information

 

	Note that not all such events will meet the criteria for relief assistance. Any individual item, or combination of items below, has a maximum of $10,000.
Qualifying Event Criteria (please check all that apply)*:	Death of employee or relative Uncontrollable loss of income resulting in potential eviction or loss of residence/home Non-insured emergency or traumatic medical expenses Hospitalization or incapacitation of employee or relative, thus resulting in employee's inability to work for greater than seven- (7) consecutive days Complete home loss due to fire or other natural cause
Employee Name*:
Employee ID#*:
Phone*:
Job Title*:
Job Status*:	Full TimePart Time
Work Location*:
Employee Mailing Address 1*:
Employee Mailing Address 2:
Employee City*:
Employee State*:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Employee Zip Code*:
Alternate Phone*:
Email*:
	Please contact your immediate supervisor or manager if you are unsure of the local HR representative nearest you.
Local HR Representative*:
Local HR Representative Contact Phone*:
Date of Event*:	Calendar
	Please provide a summary of the catastrophic event and the financial losses associated with the event. You can attach any supporting documents on Step 5.
Event Summary*: