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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