Loss of Life Assistance Form

Loss of Life Assistance
AUTHORIZATION

For a Solidarity HealthShare Sharing Member, and/or his or her dependents, who die(s) after two years of uninterrupted participation as a Sharing Member, financial assistance to the surviving family will be provided by the Members according to the following schedule, and as listed on the Sharing Member's Enrollment Application:

Primary Applicant: $10,000.00
Dependent Spouse: $5,000.00
Dependent Child: $3,000.00

Such financial assistance is to be used by the surviving family for loss of life expenses, including, but not limited to, medical, pharmacy, ambulance /emergency transportation, funeral/burial expenses.

A child applicant enrolled by a parent or guardian whose enrollment application is signed on behalf of such child by a parent or guardian, and who at the time of death is younger than 18 years of age, will be assisted at the same amount as a dependent child.
1st Recipient Choice

Please provide the name, address, and phone number for the first person you would like to authorize as the recipient of your Loss of Life Assistance.
Recipient Name*

First NameLast Name
Relation to Member*
Recipient Phone Number*
Please enter a valid phone number.
Recipient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Percentage Allocation
2nd Recipient Choice

Please provide the name, address, and phone number for the second person you would like to authorize as the recipient of your Loss of Life Assistance.
Recipient Name

First NameLast Name
Relation to Member
Recipient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Phone Number
Please enter a valid phone number.
Percentage Allocation
3rd Recipient Choice

Please provide the name, address, and phone number for the third person you would like to authorize as the recipient of your Loss of Life Assistance.
Recipient Name

First NameLast Name
Relation to Member
Recipient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Phone Number
Please enter a valid phone number.
Percentage Allocation
I hereby authorize the above person(s) as recipient(s) of my Loss of Life Assistance.
Primary Member Name*

First NameLast Name
Member ID Number*
Primary Member Email*
example@example.com
Signature*

Clear
Should be Empty:

Loss of Life Assistance

1st Recipient Choice

2nd Recipient Choice

3rd Recipient Choice