Select one.* I am an eligible employee and am submitting this application for myself I am submitting this for my direct report or my coworker I am submitting this on behalf of someone else Employee Name* First Last Employee ID* Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code If your application is approved, the grant will be mailed to the physical address you provideType of Employment Full Time (Maximum grant amount: $2,000 per household per hardship) Part Time (Maximum grant amount: $1,000 per household per hardship) PRN (Maximum grant amount: $500 per household per hardship) Please select a qualifying event.* Death of an LHC Group employee or immediate family member (as defined below) Natural disaster – LHC Group Employee Household Fire – LHC Group Employee Life threatening critical illness or injury – LHC Employee or immediate family member (as defined below and in the physician attestation) Qualifying Events Death of an LHC Group employee or immediate family member (as defined below): Grants to assist with funeral expenses will be considered when there is unexpected financial hardship. Only qualifying events that have occurred within the past 6 calendar months will be considered. Immediate family member is defined as employee’s spouse, domestic partner, dependent children, dependent step-children, or dependent children whom the employee has parenting responsibilities Must certify you have an immediate need for financial assistance Must provide proof of death in the form of funeral home documentation or a published obituary from a newspaper stating the date of the death as well the applicant’s relationship to the deceased. *A dependent is defined as being under the age of 26 unless incapable of self-care because of metal or physical disability or as a result of chronic addiction* Natural disaster – LHC Group Employee: Grants to assist with food, shelter or clothing needs will be considered when an event or force of nature (such as earthquake, flood, forest fire, hurricane, lightning or tornado) leads to catastrophic consequences to the employee’s home. Only qualifying events that have occurred within the past 6 calendar months will be considered. Must certify you have an immediate need for food, clothing or shelter. Please provide proof of damages resulting from the disaster (photos or documentation). Household Fire – LHC Group Employee: Grants to assist with food, shelter or clothing needs will be considered when fire makes the employee’s primary residence uninhabitable. Only qualifying events that have occurred within the past 6 calendar months will be considered. Must certify you have an immediate need for food, clothing or shelter. Must provide copy of the fire report. Life threatening critical illness or injury – LHC Employee or immediate family member (as defined below and in the physician attestation): Grants to assist with financial hardship incurred as a life threatening result of critical illness or injury* to you or your immediate family (spouse, domestic partner, dependent children, dependent step-children, or dependent children whom the employee has parenting responsibilities). Only qualifying events that have occurred within the past 90 calendar days will be considered. Must certify you have an immediate need for financial assistance. *Must complete and return the physician’s attestation. (Can be found on the Documents page)* *Critical illness or injury is defined as a life threatening medical condition which requires a person to be under the active care and treatment by a physician which require periodic visits for treatment that continue over an extended period of time, and may cause episodic incapacity (inability to work or perform other regular daily activities due to the serious health condition), e.g., heart attack, stroke, cancer, end-stage renal disease, major third-degree burns or paralysis. *A dependent is defined as being under the age of 26 unless incapable of self-care because of metal or physical disability or as a result of chronic addiction* Click here to download the Physician Attestation Form Qualifying Event Document of Proof (Physician Attestation, Obituary/funeral home documentation, fire report, or photos of damage to primary dwelling due to natural disaster)*Max. file size: 50 MB.*Must submit for your application to be considered*
