Encompass Cares Special Employee Assistance Application - Hurricane Michael 2018

Complete entire application and provide as much detail regarding your circumstance as possible

Name:*
Address:*
Personal Phone:*
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Work Phone:*
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E-mail:*
Work location (ex: Panama City, FL Home Health)*
Are you a current Encompass Cares donor?*

NOTE: Incomplete requests will not be processed. Supporting documentation and signatures are required and must be submitted with the application (examples of documentation include: policy/fire report, doctor’s note and other related documentation). Documentation must be on letterhead or statement of owned party.

1. Please describe your emergency and circumstances in detail (including all dates):*

2. Are you currently, or have you within the past 12 months, received any financial assistance from the following sources: Worker's Compensation, short-term disability, long-term disability, insurance, state/federal agencies, non-profit agencies, fundraising efforts, or any other entity that is assisting you with your financial hardship? If so, please list the amount of money received and frequency of assistance.

Total $ received:
Frequency of assistance:
3. Amount of financial assistance requested from Encompass Cares:*