GMR - Request For Assistance Form

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

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.

Employee Name

Employee ID#

Phone

Job Title

Job Status Full Time Part Time

Work Location

Employee Mailing Address 1

Employee Mailing Address 2

Employee City

Employee State

Employee Zip

Alternate Phone

Please contact your immediate supervisor or manager if you are unsure of the local HR representative nearest you.

Local HR Representative

Local HR Representative Phone

Date of Event

Event Summary

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.

Step 2 of 5: Employee Information

Do you have insurance to cover any portion of the loss or event?

Amount Covered

Amount Not Covered

Please Explain

Number of Days Missed

Number of Days Missed Unpaid

If a medical event, do you have short term or long term disability insurance to cover unpaid time? Yes No

Step 3 of 5: Insurance Information

Non-Insured medical expenses excluding Co-Pays & Deductibles

Temporary Housing Expenses

Car Rental Expenses

Funeral/ Burial expenses

Other

Please Explain

Please attach supporting Expense documents on Step 5.

Have you exhausted all personal sources of income or savings that can help you cover the losses to Include, but not limited to, reducing unnecessary household expenses, 401K disbursements/loans and family assistance? Yes No

Please Explain

Have you applied for all available relief programs from local, state and/or federal agencies?: Yes No

Please Explain

Step 4 of 5: Income and Expense Information

Automatically Total Monthly Wages

Other sources of income or savings that can help you cover the losses

Please Explain

Mortage / Rent

Utilities

Gasoline / Transportation

Credit Cards

Bank / Car Loan Payments

Food

Medical / Pharmacy

Other

Please explain any other expenses (i.e. child support, alimony, etc)

Step 5: Upload Supporting Documents & Certification

Contact your Supervisor or HR Representative if you have questions regarding the documents to attach.

Supporting Document for Event 1:

Please select a file

Please attach supporting documents for the financial losses associated to your catastrophic event.

Supporting Document for Event 2:

Please select a file

Please attach supporting documents for the financial losses associated to your catastrophic event.

Expense Document 1

Please select a file

Please attach documents for Expenses related to your loss.

Expense Document 2

Please select a file

Please attach documents for Expenses related to your loss.

Expense Document 3

Please select a file

Please attach documents for Expenses related to your loss.

I certify that all information provided above in this form is true and complete. I understand that any false information or omission may disqualify me from further consideration for relief payments.

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Request For Assistance Form

Step 1 of 5: Employee Information

Step 2 of 5: Employee Information

Step 3 of 5: Insurance Information

Step 4 of 5: Income and Expense Information

Step 5: Upload Supporting Documents & Certification