Mutual Aid Ministries Individual Grant Request Form

Please review our Individual Grant Guidelines 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.

Person Completing This Request

Question Title

* 1. Person Completing This Request

Name

Email Address

Phone Number

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

Question Title

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

Yes

No

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

Question Title

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

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

Question Title

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

Yes

No