Illinois H.B.P.A. Benefit Trust Application for Assistance

 
Health ____________           Financial ____________

Name ___________________________ SSN _____-_____-_____

Date of Birth ______/____/______
 
License Type:  Trainer__________  Other_____­­­­­______________

Employer: ____________________________________________
 
Reason for Claim: ______________________________________

Do you have health insurance? _________________________
 
I certify that all answers given are true. I hereby authorize the H.B.P.A. to receive information concerning my request for assistance.

Date: ____________   Signature: _________________________

 
This application has been reviewed by the Benevolence Committee.
 
Approved________________________   Denied ______________________

Approved________________________   Denied ______________________

Approved________________________   Denied ______________________
  
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