Electronic Application - CFA FoundationCFA Foundation

Apply > Electronic Application

To apply for foundation assistance, please fill out the form below.

Applicant Information
Worker's Full Name*
First Last
Worker's Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Number of dependents (including minor children of the applicant)*
Employer at Time of Injury*
Employer Address*
Street Address City State ZIP Code
Name of Person Submitting*
Phone*
Email*
Relationship to Worker
Who should we contact for additional information? (Enter their full name.)
Relationship to Worker
Phone
Email*
Incident / Injury Information
Was this a construction or facilities maintenance-related incident at an Indiana jobsite?*
- Yes
- No
If you answered no, please explain.
Was the applicant fatally injured?*
- Yes
- No
Please describe the incident and resulting injury.
Date of Incident*
MM slash DD slash YYYY
Location of Incident (please include name of facility if applicable)*
How has this injury/fatality affected the worker and his or her family?*
Please use this space for any additional information you feel the CFA Foundation Board should know
Please attach any documents relative to this application for CFA Foundation assistance.
Accepted file types: jpg, pdf, Max. file size: 16 MB.
Verification of Information
Verification*
- By checking this box, I certify the information on this application is factually correct to the best of my knowledge.
Captcha

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