Viemed Employee Emergency Relief Fund Application

The Viemed Employee Emergency Relief Fund is designed to provide immediate financial assistance to active Viemed employees who experience financial hardships resulting from unanticipated and unavoidable emergency situations.

Hurricane Ida Application Deadline: Friday, October 29, 2021

Eligibility Requirements:

Applicant must be an active, full-time* employee of Viemed
- Active employee can apply for situations related to immediate family members ("Immediate" is defined as a spouse, child or stepchild)
Must be employed by Viemed for at least 90 days prior to applying
Must apply within 60 days of the incident
Limited to one grant per category per year
Limited to one grant per legal dependent** each year

*Full-time employment is defined as 30 or more hours per week

**Employees can apply for grant assistance for situations involving legal dependents. We will consider legal dependents as they are defined by the IRS - persons other than the taxpayer or spouse who entitles the taxpayer to claim a dependency exemption.

Qualifying Situations/Categories:

1. Natural Disaster: events officially declared by Federal, State or Parish governments including wildfires, floods, tornados, hurricanes, severe storms or earthquakes that damage or destroy the employee’s primary residence.

2. Medical Emergency: for the employee, spouse or eligible dependent(s). The Fund is not a substitute for medical insurance but will help meet deductibles or cover travel expenses. For medical emergencies, doctor confirmation or medical documentation will be required.

3. Death Incident: includes death of the employee, spouse or eligible dependent(s). Includes death care or funeral costs that prevent an employee or the employee’s family from affording basic living expenses. Also, the fund may help to pay for relocating a child whose parent(s) have died.

4. Material Related Hardship: includes non-declared, individually experienced situations such as house fires and other major material damaging events.

Please note:

All applications will be subject to a confidential and objective review and will be approved or denied by a committee of Community Foundation of Acadiana on behalf of Viemed
Proper documentation will be required for grant assistance and will be requested if not provided
The amount granted to an applicant can never exceed the available fund balance at the time of the application

A red asterisk (*) indicates a required field.

Select a Choice:*

Employee Name:*

First NameLast Name

Date of Birth*

Last 4 digits of Social Security Number:*

Phone Number:*

E-mail:*

example@example.com

Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Have you been employed with the company for at least 90 days?*

YesNo

You MUST be employed for at least 90 days to be considered for assistance from the Viemed Employee Emergency Relief Fund. Any employee who has not met this employment threshold will not be eligible.

Were you an active employee at the time of the incident?*

YesNo

You MUST be an active employee at Viemed now AND at the time of the applied-for incident to be considered for assistance from the Viemed Employee Emergency Relief Fund.

Which qualifying situation caused the financial hardship? (Hover over text to see definitions of the options below and choose the one that best fits your circumstances)*

Natural DisasterMedical EmergencyDeath IncidentMaterial Related Hardship

Type of incident (ex: tornado, fire, type of injury, name of illness, etc.)*

Date of incident (must be subsequent to 12/1/20 and within the last 60 days to be eligible for assistance):*

Date

Of the scenarios below, please select all that applied to you personally as a result of this disaster:*

Describe what has happened to cause your financial hardship and your immediate needs:*

Estimated dollar amount of immediate relief needed:*

Ex: $1,200

What does the above amount cover?*

Ex: Amount of deductible, out of pocket medical expense, etc.

Total household income level (should include spouse, partner, etc.):*

Do you own or rent your primary residence?*

OwnRentNeither

What is your monthly mortgage or rental payment for your primary residence?*

What is your monthly car payment(s)?*

Number of legal dependents at time of incident:*

Please estimate your out of pocket expenses incurred or to be incurred from damages, losses and expenditures detailed in the application that are NOT expected to be covered by insurance, government assistance, FEMA, or from other sources. Please exclude the costs associated with nonessential, luxury or decorative items and services:*

Are you requesting additional relief from other sources? (Ex: FEMA, payments for medical or counseling services, temporary housing, etc.)*

YesNo

Can we share your story anonymously to help us build this program? (Your identity will not be disclosed)*

YesNo

Please upload up to 6 documents/pictures substantiating your situation. These could include photo evidence of home damages, insurance documents/deductibles, repair estimates/invoices, death certificates, medical bills, proof of home ownership, etc.

**If this information is not provided initially, it will be requested and could delay or inhibit the grant distribution process**

Upload up to 6 pictures / files:*

I attest the information furnished above is true to the best of my knowledge. I also understand the Fund reserves the right to require and seek verification of information submitted on this application with my employer. Finally, I agree to confidentiality on the process and amounts granted to me through this employee grant process.*

YesNo

Personal Information

Financial Information

Attach Supporting Documentation