Apply

Current and past licensed members and their families of the INDYCAR sanctioned motorsports community may apply for aid for those who find themselves in financial or other needs due to hardship caused by illness, injury or death. Applications will be considered whether or not the hardship condition is the result of on the job related or from other reasons.

We are here to help

Name(Required)

First Last

Email(Required)

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Professional Affiliation

Motorsports Partcipant

Relative of Indy Car Participant

Sanctioning Body

If relative of Indy Car participant, please state relationship

Reason for Requesting Assistance

Include nature of illness, injury or circumstances regarding death

Nature of Illness or Injury

Date of Occurence

Current Financial Status(Required)

Employed

Unemployed

Occupation(Required)

Employer(Required)

Employer Contact

Phone

Has employment stopped due to this problem?

Yes

Date Employment Stopped(Required)

Date Employment Resumed

Worker's Compensation - Weekly Amount

in US dollars

Disability Benefits - Weekly Amount

in US dollars

Unemployment Benefits - Weekly Amount

in US dollars

Other Sources of Income and Assistance

in US dollars

Veteran's Compensation

in US dollars

Medicare

in US dollars

Social Security Benefits

in US dollars

Pension

in US dollars

Signature

Are you applying on behalf of a person needing assiatance?

Yes

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Relationship to Applicant(Required)

I authorize any physician, medical practitioner, hospital, clinic, Veteran's Administrati n facility, other medically related facility having information available as to diagnosis, treatmen ,and prognosis with respect to any physical condition and/or treatment of me to give to Th Benevolent fund of Motorsports, Inc. any an' d all such information.(Required)

I do

All applications will be held in confidence

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