Intake Form

Welcome to the Clergy Assurance Fund Benefits and Grants Form.
Use this form to update your policy information, enroll, designate a beneficiary, or apply for one of our grants.

Most people finish in about 5–10 minutes.

If you have your Policy Number handy, please have it ready. While not required, it helps us speed up the location of your policy.

Some questions will require supporting documents which will help in determining our ability to help. Please upload those when required.

All amounts are subject to annual limits per fiscal year.

About You
I am Clergy.I am a Clergy Spouse or other Family.I am none of the above.

Clergy or Members
What's your full name?*

TitleFirst NameMiddle NameLast NameSuffix
What's your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What's your email address?*

Confirmation EmailWe'll send your confirmation and any follow-up to this address.
What's the best phone number to reach you?*

Country CodeArea CodePhone Number
What is your date of birth?*

MonthDayYear
What is your clergy status?*
Which diocese are you currently serving in?*
EnrollManage my PolicyApply for a Member GrantOther

Clergy Spouse or Family
What's your full name?*

TitleFirst NameMiddle NameLast NameSuffix
What's your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What's your email address?*

Confirmation EmailWe'll send your confirmation and any follow-up to this address.
What's the best phone number to reach you?*

Country CodeArea CodePhone Number
What is the Member or Policy Holder's full name?*

TitleFirst NameMiddle NameLast NameSuffix
Submit a ClaimApply for a Family GrantOther

Neither Member nor Family
We understand that not every family fits into neatly defined categories, and we are dedicated to helping clergy and their families with any situations that may arise. Please email us at operations@clergyassurancefund.org or call us at (215) 557-6960 so that we can determine how best to serve you. We are committed to responding with the utmost care.

If this is a spiritual matter and you'd prefer to speak with the Chaplain, please email at chaplain@clergyassurancefund.org or call (215) 557-6960 and we'll reach out to you as soon as possible.

Thank you and God bless.

Options Not Listed
If you need help with something that's not listed in these options, please email us at operations@clergyassurancefund.org or call us at (215) 557-6960 so that we can asses how best to serve you. We are commited to serving clergy and their families witht he utmost care.

Manage my Policy
Policy Number
Update my Information.Designate or Update BeneficiariesRequest or Purchase Additional Coverage

Update my Information
New Mailing AddressNew EmailNew Phone NumberOther (Please describe the update needed.)
- Please enter your new mailing address.
  
  Street Address Line 2
- What's your new email address?
- What's your new phone number?

Beneficiary Designation
Who is your primary beneficiary?*
What is their relationship to you?*
What percentage of benefit should they receive?*

Purchase Additional Coverage

All requests are subject to review and adjustment.
What is your place of birth?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your current order or status?*
How much would you like to request for insurance?*
Please indicate in $1,000 increments.
Insurance Limits:

To age 40: $150,000

Age 41-50: $100,000

Age 51-60: $75,000

Age 61-72: $50,000
Pay in Full - 1 PaymentMonthly - 180 PaymentsQuarterly - 60 PaymentsBi-annual - 30 PaymentsAnnual - 15 Payments

Apply for a Member Grant

Grants are subject to annual limits.
Wellness Grant — Up to $5,000Spiritual Renewal Grant — Up to $1,500Sabbatical Grant — Up to $5,000Spousal Death Benefit — $5,000
- What type of expense is this?
- Please describe the expense.
- How much are you requesting?
- Upload receipts, bills, or any other documentation.
  
  Cancelof
- What kind of spiritual renewal are you seeking?
- When does the experience start?
  
  YearMonthDay
  Date
- Please describe the experience.
- How much are you requesting?
- Upload Documentation
  
  Cancelof
- When is the first day of your sabbatical?
  
  YearMonthDay
  Date
- When is the last day of your sabbatical?
  
  YearMonthDay
  Date
- Describe your sabbatical plan.
- How much are you requesting?
- Upload approval letter from your bishop.
  
  Cancelof
- What was the date of death?
  
  YearMonthDay
  Date
- Please upload the death certificate.
  
  Cancelof

Submit a Claim
What's the policy number?
What was the date of death?*

MonthDayYear
Please upload the death certificate.*

Cancelof

Apply for a Family Grant
Supplemental Income GrantEmergency Aid Grant — Up to $5,000Educational Grant — Up to $7,000
- This form is for surviving spouses of clergy seeking need-based Supplemental Income. Please answer each question completely and accurately. All information is confidential.
  
  For questions, contact: operations@clergyassurancefund.org.
- Household Information
- Children living with you (under 18)
- Children living with you (18 and older)
- Other family members living with you (dependent)
- Other family members living with you (independent)
- Housing Information
- Housing Costs
- Mortgage
- Mortgage Payment Amount
- Mortgage Payment Frequency
- Other Housing Expenses
- Property Taxes - Amount
- Property Taxes - Frequency
- Utilities - Amount
- Utilities - Frequency
- Home Insurance - Amount
- Home Insurance - Frequency
- Car Insurance - Amount
- Car Insurance - Frequency
- Medical Expenses
- Health Insurance - Amount
- Health Insurance - Frequency
- Other Regular Expenses
- Expense #1 — Description
- Expense #1 — Amount
- Expense #1 — Frequency
- Expense #2 — Description
- Expense #2 — Amount
- Expense #2 - Frequency
- Employment
- Employment Status
- Take-home Wages — Amount
- Wages - Frequency
- Other Income
- Savings and Investments
- Savings or Money Market Funds — Total Value
- Investments (stocks, bonds, mutual funds) — Total Value
- Investment Income — Amount
- Investment Income — Frequency
- Other Sources of Support
- Trust Accounts — Amount
- Trust Accounts — Frequency
- Financial Support from Family — Amount
- Financial Support from Family - Frequency
- Additional Income Sources
- Income Source #1 — Description
- Income Source #1 — Amount
- Income Source #1 — Frequency
- Income Source #2 — Description
- Income Source #2 — Amount
- Income Source #2 - Frequency
- Additional Comments
- Please write down anything else that you'd like to share.
- Describe the emergency.
- How much are you requesting?
- Please upload any documents that may help us make a determination.
  
  Cancelof
- Name of School
- How much are you requesting?
- Upload Enrollment Verification
  
  Cancelof
- Upload Tuition Statement
  
  Cancelof

Form Submission and Signature
Signature*

Clear
Should be Empty:

Welcome to the Clergy Assurance Fund Benefits and Grants Form.

About You

Clergy or Members

Clergy Spouse or Family

Neither Member nor Family

Options Not Listed

Manage my Policy

Update my Information

Beneficiary Designation

Purchase Additional Coverage

Apply for a Member Grant

Submit a Claim

Apply for a Family Grant

Household Information

Housing Information

Mortgage

Other Housing Expenses

Medical Expenses

Other Regular Expenses

Employment

Other Income

Savings and Investments

Other Sources of Support

Additional Income Sources

Additional Comments

Form Submission and Signature