Thoroughbred Horsemen’s Health Fund Application

THOROUGHBRED HORSEMENS HEALTH FUND
BENEVOLENCE REQUEST FORM

APPLICANT ________________________________________TRAINER______STABLE EMPLOYEE ____

OR DEPENDENT: NAME _________________ IF UNDER THE AGE OF 18, DATE OF BIRTH____________

RELATIONSHIP TO APPLICANT ____________________________________________________

ADDRESS________________________________________________________________________________
STREET CITY STATE ZIP
BADGE #______TELEPHONE____________DATE OF BIRTH_____SOCIAL SECURITY #_____________

STABLED AT_________AT TIME OF ILLNESS____INJURY_____PLEASE EXPLAIN ON BACK OF PAGE

TRAINERS: MUST LIST NUMBER OF OHIO STARTS LAST YEAR__________________=%____________
TRAINERS: MUST LIST NUMBER OF OUT OF STATE STARTS LAST YEAR_________=%___________

ORIGINAL ITEMIZED BILLS MUST ACCOMPANY REQUEST WITHIN SIX MONTHS OF SERVICE DATE

MEDICARE________OR PRIVATE MEDICAL INSURANCE COMPANY NAME AND DEDUCTIBLE__________________________________________________________________________

APPLICANTS AUTHORIZE RELEASE OF ALL APPLICABLE MEDICAL RECORDS. RECORDS WILL BE KEPT ON FILE FOR A PERIOD OF THREE YEARS. ONE FREE COPY MADE AVAILABLE UPON WRITTEN REQUEST BY HORSEMAN OR PROVIDER OF SERVICE.

APPLICANT WARRANTS HE HAS NOT PREVIOUSLY ASSIGNED, COMPROMISED OR RELEASED ANY CLAIMS HE MIGHT HAVE AGAINST ANY THIRD PARTY, LEGALLY LIABLE FOR THE REQUESTED BENEVOLENCE.

THE UNDERSIGNED SAYS THAT ALL STATEMENTS CONTAINED IN THE FORGOING APPLICATION ARE TRUE.

SIGNATURE OF APPLICANT___________________________________________________DATE_______

EMPLOYMENT VERIFICATION FOR STABLE EMPLOYEES

PLEASE NOTE: FRAUDULENCE WILL RESULT IN LIFETIME LOST OF ELIGIBILITY FOR BOTH STABLE EMPLOYEE AS WELL AS EMPLOYER THAT SIGNS THE REQUEST FORM.

I DO HEREBY VERIFY THE ABOVE NAMED EMPLOYEE WORKS FOR ME ON THE GROUNDS OF AN OHIO RACETRACK _______HOURS PER WEEK. EMPLOYEE MUST PROVIDE A COPY OF A “GROOM” LICENSE AND MUST BE A “FULL-TIME” GROOM ONLY. PERSONS WITH MULTIPLE LICENSES WILL NOT BE ELIGIBLE.

SIGNATURE OF TRAINER___________________________DATE________

PRINT NAME________________________________________________
SEND TO: THOROUGHBRED HORSEMEN HEALTH FUND
3684 PARK STREET, GROVE CITY, OH 43123
1-800-321-8367 / FAX 1-614-875-0786 REVISED 01/01/05