Mutual Aid Ministries Individual Grant Request Form

Please review our Individual Grant Criteria here before completing the form below. If you have any questions about our Mutual Aid Ministries Individual Grant Request form, please contact us at info@maxinsurance.com.

* 1. Person Completing This Request

Name

Email Address

Phone Number

* 2. Are you currently insured by MAX directly, or through one of our independent agents?

Yes

No

* 3. Relationship to Grant Recipient (member of my church, relative, neighbor, friend, etc.)

* 4. Does the Grant Recipient know you are submitting this request on their behalf?

Yes

No