Bobby Salmon Big "I" Relief Fund

Bobby Salmon Big "I" Relief Fund
The Fund was created to provide the insurance industry, including IIABA staff, members, their agency employees, and others, with a vehicle to make financial contributions to aid independent insurance agencies and brokerages and their owners and employees with immediate or ongoing financial needs when other funding sources (such as insurance, grants, or federal or state loan programs) are not available, and to support other recognized tax-exempt organizations providing such relief and assistance to independent insurance agencies and brokerages and their owners and employees to fill the gap until other funding sources can be accessed. The types of expenses the Fund will cover are listed under the Use of Funds section of these Guidelines. To make a donation to the Fund, simply click here to be brought to an online donation form. If you wish to apply for a grant from the Fund, complete the form below.
Are you applying on behalf of an insurance agency or individual?*

Insurance AgencyIndividual
What is the name of the insurance agency/business?
Please use the business's legal name.
Name*

First NameLast Name
Insurance Agency/Business EIN/Tax ID:
Please enter the Employer Identification Number of the entity applying for the grant using the XX-XXXXXXX format.
Individual's SSN:
Please enter the Social Security Number of the individual that is applying using the XXX-XX-XXXX format.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter the best phone number to use to contact the applicant.
Email*
example@example.com

Please enter the dollar amount being requested for this grant:*
Please provide the amount that you are requesting from the Fund (not covered by other funding sources such as insurance, grants, or federal or state loan or grant programs). Please refer to the list from the "Use of Funds" section in the Bobby Salmon Big "I" Relief Fund Guidelines for guidance.
Please describe the situation or other eligibility qualifications, and the intended Use of Funds, if awarded a grant. Please provide as much detail as possible.*
Eligibility criteria and Use of Funds are described in the Bobby Salmon Relief Fund Guidelines. A link to this document is included at the top of Page 1 of the form.
In order to approve your grant and comply with IRS regulations and the Foundation's guidelines, we require documentation to support this application. Please provide any documentation that will support your application for grant funding. This may include receipts, contracts, medical bills or other documents indicating economic impact.*

Accepted file types include pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof

Agreement

Please carefully read the agreement below and indicate your acceptance by using the e-signature below.
By submitting this form, I agree that the Fund is authorized to acknowledge any grant to me in press releases, publications or social media, to transmit any grant it approves for me to the appropriate IIABA state association, if applicable, for delivery to me, and as part of its due diligence, to share my information with IIABA state associations and /or relief organizations. I also certify, under penalty of perjury, that: i) all information in this Application Form is true and correct; ii) I will notify the Bobby Salmon Relief Fund in writing of any material changes to the application prior to receiving any grant from the Bobby Salmon Big "I" Relief Fund; and iii) if the application is on behalf of a business, I am authorized by the business to complete and submit it.
Signature*

Clear
Please verify that you are human*
Should be Empty:

Bobby Salmon Big "I" Relief Fund

Agreement