Emergency Relief Fund Application It is required that you read and acknowledge the Emergency Relief Fund Policy and the Emergency Relief Fund Rules before submitting the application below. Emergency Relief Fund Policy Emergency Relief Fund Rules Complete the Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.AcknowledgementCheck Box After Reading Documents *Yes, I have read the Emergency Relief Fund Policy and the Emergency Relief Fund RulesNo, I have not read the Emergency Relief Fund Policy and the Emergency Relief Fund RulesPersonally Identifying InformationLayoutTitle *Home Phone *TitleFirst Name *Alt. PhoneEmployee IDMiddle NameEmail *Work PhoneLast Name *LayoutAddress *State/Province *2-character abbreviationCountryDescription of ProblemCity *Zip *5-character zip codePurpose of Request *What is the purpose of this request? Describe the circumstances that led to the emergency and the extent of the problem.Amount Needed and Specifics *Please provide the actual amount needed to overcome this immediate emergency, as well as the supporting specifics and documentation.Other Applications for Assistance *What other agencies or organizations have you applied to for assistance? Have you received any financial help to date? If so, how much?Other Reimbursements *Do you expect a settlement or other reimbursement from any source to help with your emergency? If so, how much? Please explain.Insurance Policy *YesNoDo you have an insurance policy that covers these circumstances and if so, what is the deductible?If "Yes," Enter Deductible AmountUpload Proof of Emergency Document Click or drag a file to this area to upload. (Optional) upload proof of emergency documentation (police/fire report, death certificate or other). One file only. 24 MB limit. Allowed types: gif, jpg, png, bmp, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3.Submit Application Emergency Request Legal Benefits Legal Defense General Counsel Donate About Overview Bylaws Meet the Board Contact
