Eagle Insurance Group Financial Affidavit For Hardship

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EAGLE INSURANCE GROUP
APPLICATION FOR HARDSHIP DISTRIBUTION
This entire Application, including the Financial Affidavit (except where such Financial Affidavit is not required),
must be fully completed in order to be evaluated.
INSTUCTIONS AND EXPLANATION FOR HARDSHIP DISTRIBUTIONS
The procedures described herein have been established by the Commissioner of Banking and Insurance of the State of
New Jersey to protect the individual policyholders and claimants of the Eagle Insurance Company and its subsidiaries
(Newark Insurance Company, GSA Insurance Company and National Consumer Insurance Company) in Rehabilitation
(hereinafter Eagle Insurance Company and its subsidiaries shall be collectively referred to as “Eagle Insurance Group”).
These procedures and guidelines are essential to ensure that all applicants are treated uniformly and fairly during the
time that Eagle Insurance Group is in Rehabilitation. Our objective is to ensure that the assets of Eagle Insurance Group
are preserved to the greatest extent possible to protect all policyholders and claimants.
A circumstance of extreme hardship justifying a hardship distribution shall be found to exist only when one or more of the
following facts and circumstances has been established to the satisfaction of the Commissioner by sworn statement
supported by adequate documentation provided by the policyholder, claimant or his or her duly-authorized representative
and there is an approved claim, settlement or judgment. All hardship distributions will be limited to a lifetime maximum of
$10,000 per policyholder or claimant. NOTE: Further limitations on distributions are indicated below.
Under the terms outlined above, the undersigned hereby applies for a hardship distribution. All amounts paid under this
application will be deducted from future amounts payable to the applicant when applicable. This entire application is
made to satisfy an immediate and pressing financial need arising from one or more circumstances checked below
which represent a legal obligation of the applicant, and which cannot be met by other reasonable available resources.
Name______________________________________
SS#_________________________DOB___________________
Address____________________________________
Employer___________________________________________
City, State, Zip_______________________________
Policy/Claim No.______________________________________
Business Phone #____________________________
Home Phone #_______________________________________
AMOUNT OF HARDSHIP DISTRIBUTION REQUEST ($10,000 maximum)............$_____________________________
The entire application is being made to satisfy an immediate and pressing financial need arising from one or more of the
circumstances checked below which represents a legal obligation of the applicant and which cannot be met by other
reasonable available resources. The Applicant certifies that he or she:
Is unable to pay for essential shelter. (Provide copies of any eviction or foreclosure notice).
Is unable to pay for essential and necessary medical treatment (such as surgery, prescription medication,
therapy, etc.) that is not covered by any health, automobile or other insurance coverage, including, but not
limited to, self, spouse/domestic partner, dependents, homeowners, commercial or other automobile. (Provide
copies of all medical bills, indicating insurance coverage, and denials by all insurance companies).
Faces imminent removal from a hospital, nursing home or other medical care facility or imminent cessation of
home health or custodial care because of inability to pay. (Provide copies of all medical bills, indicating
insurance coverage, and denials by all insurance companies and supporting statement from the medical care
facility or care provider).
Cannot pay the funeral expenses of spouse/domestic partner or dependent. (Copy of unpaid funeral bill
required.)
Due to total disability, is unable to meet current financial obligations. (Provide a Physician’s Statement as to the
total disability and a copy of the Social Security Disability Award, if available.)
Is suffering from a terminal illness resulting in a severely limited life expectancy. (Provide a Physician’s
Statement certifying the terminal illness and remaining life expectancy.)
NO FINANCIAL AFFIDAVIT IS
REQUIRED.
Is unable to pay any federal, state or local authorities any tax or fine such that such authority has issued a
Notice of Intent to Levy. (Provide copies of such notice.)
Is experiencing some emergency or some other serious situation of an unusual nature which the Commissioner
may deem appropriate based on materials attached hereto. (Explain your situation on a separate sheet of paper
and attach all supporting documents).

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