Priest Auto Insurance Reimbursement Request Form
Only retired priests, priests serving in institutional ministries, priests with diocesan car loans, and seminarians should use this form. Active priests must submit their request directly to their parish bookkeeper.
Name
*
Prefix
First Name
Last Name
Email
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Select one:
Retired
Institutional Ministries/Chaplain
Diocesan Car Loan
Seminarian
Reimbursement Amount Being Requested (limit $1,500 per year)
*
Dates of Coverage:
Date
*
to
Date
*
.
Please attach your Declarations Page showing liability limits of $250,000 per person/$500,000 per accident.
*
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Please attach a receipt, payment confirmation, or copy of your check as evidence of payment.
*
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Submit
Should be Empty: