The ESP International Charitable Foundation may help employees who are unable to pay for housing, utilities, food, clothing and other basic living expenses because of a life-threatening or serious illness or injury of the employees or eligible dependant. The Foundation is not a substitute for medical or other insurance, and it cannot pay deductibles or medical bills. Employees do not automatically qualify for a grant when they, or a member of their family immediate family, are diagnosed with or suffer a life-threatening or several illness or serious injury. There must be resulting financial need including an inability to pay basic living expense

 

What's Covered:

 

What's Not Covered:

 

 

Assistance Application/Vendors to be paid

 

Date of injury or onset of illness*


Who has been affected by the illness/injury*


What is the medical condition of the person*


Is the affected person covered by medical insurance*
   


Is the affected person covered by disability insurance*
   


Is the affected person covered by disability benefits*
   


Describe in detail the employees immediate needs*


How will this grant help the employee recover from the immediate financial crisis*


Please tell us anything else that would help us understand the circumstances related to the economic hardship you are experiencing


Submitted by*


Vendor Name and Address*


Basic need provided through service*


Amount Owed*


Date payment due*


Account number*


Vendor Name and Address - 2


Basic need provided through service - 2


Amount Owed - 2


Date payment Due - 2


Account Number


Vendor Name and Address - 3


Basic need provided through service - 3


Amount owed - 3


Date payment due - 3


Account Number - 3


Email Address - Who submitted*


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Important: Any doctor's letter regarding the affected person's condition or letter regarding disability coverage or other related documents regarding the situation must be submitted with this application.

 

 Document Checklist: (These need to be completed before application is considered)

___ Assistance Application

___ Incident Report

___ List of vendors to be paid

___ Additional documentation as requested