Printing Illness or Injury

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:

Medical expenses (not eligible for reimbursement by insurance)
Past due rent or mortgage payments
Property modification such as a wheelchair ramp
Limited hotel accommodations to accompany hospitalization qualified dependant
Past due essentials utility bills (electricity, heat, water, etc.)
Basic living expenses such as food and clothing

What's Not Covered:

Credit card, auto and other debts
Non-essential utilities (cable, phone, etc.)
Lost wages

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*

Yes

No

Is the affected person covered by disability insurance*

Yes

No

Is the affected person covered by disability benefits*

Yes

No

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 - 2

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* Send me a copy of form

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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