To fill out this form you will need:
·     2 months account (banking) statements with full transactions (i.e. Chime, Walmart, Wisely pay cards)
·     Last 2 pay stubs
·     All invoices or bills requesting to be paid - We do not cover medical bills.

If this is for a death of an immediate family member, the letter of statement or funeral expense invoice is needed.

Personal Information

First Name

Last Name

Primary Phone

Social Secuirty Number

Relationship to SHC

SHC Community you are affiliated with

Radius to SHC Facility

Who is your Internal SHC contact

Marital Status

How many children under 18 are in your household

Ages of Children in Household

Current Mailing Address

City

State

Postal Code

How did you hear about the SHC Compassion Fund

Would you like to speak to a chaplain?

Who told you about the Compassion Fund

Other

How Long have you worked for Signature HealthCare?

What shift do you work?

You will be notified of your Emergency Assistance application status by email. Please verify that you have provided valid contact information. You will only receive communication concerning your application.

If Awarded, Do you want monetary award sent to your facility?

Address to send award to

Emergency Assistance Information

Reason for Support (Required)

Is this COVID-19 related?

Other Circumstances

Is Money owed to a company?

Company Address

Company Phone Number

Did you get your test from a SHC Facility?

When did you receive your positive test result?

Funeral Home Name

Funeral Home Phone Number

Funeral Home Address

Do you have insurance converage

Do you have a deductible

Name of insurance company

Total Amount Requested

Explain how your award will be used. Please list the dollar amount per item. (e.g. Rent - $500)

Have you received an emergency assistance award within the last 12 months? (Required)

Date last award received

Why are you requesting assistance from the Compassion Fund?

File Uploads needed

If you need to add additional files, click the

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Last 2 pay stubs (Required)

Last 2 pay stubs (if needed)

Last 2 months account (banking) statements with full transactions (Required)

Last 2 months account (banking) statements with full transactions (if needed)

Invoices/bills (Required)

Invoices/bills (if needed)

Incidental Documents (if needed)

Upload verification of test results

All other incidental documentation - if request is for Death of Immediate Family Member - Letter of Statement or Funeral Expense Invoice is needed

The Compassion Fund seeks to provide support to employees in times of catastrophic events. A committee will review all requests for assistance. Awards are determined on a case-by-case basis and the amount of your assistance may not equal the amount you have requested. Depending on the situation, you may be asked to provide documentation that supports the details of your emergency.

Contact Information