survivor fund request for monetary assistance...

International Towing & Recovery Phone: (423) 267-3132 Hall of Fame and Museum Fax: (423) 267-0867 3315 Broad Street Email: [email protected] Chattanooga, TN 37408 www.towingmuseum.com

© 2014 International Towing and Recovery Hall of Fame and Museum, Inc.

SURVIVOR FUND REQUEST

FOR MONETARY ASSISTANCE AND

REQUEST FOR INCLUSION ON THE WALL OF THE FALLEN

***DEATH MUST HAVE OCCURRED WHILE THE DECEASED WAS ON THE JOB***

Date of Submission: ___________________ Applying for: □ Survivor Fund □ Wall of the Fallen □ Both Name of the Deceased: ______________________________________________________________________

Sex: □Male □ Female Date of Birth ___________________ Date of Death: _____________________ Name of Deceased’s Legal Spouse (if applicable): _________________________________________________ Name(s) and Age(s) of Deceased’s Children (if applicable): _________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Name of Company the Deceased Worked For: ____________________________________________________ Company Contact: __________________________________________________________________________ Company Address: __________________________________________________________________________ City: __________________________ State: ________ Zip: __________ Country: ____________________ Phone: ___________________ Fax: ___________________ E-mail: ________________________________

Years in the Towing Industry: □ Less than 2 years □ 2 -5 years □ 5-10 years □ Greater than 10 years Position of Deceased with the Company: ________________________________________________________

ITRHFM Member: □ Yes □ No Name of Submitter: ___________________________ Relationship to Deceased: _______________________ Physical Address: __________________________________________________________________________ City: __________________________ State: ________ Zip: __________ Country: ____________________ Phone: ___________________ Fax: ___________________ E-mail: ________________________________

Date of Incident: ________________ Time: ______ □am □pm City: _____________________ State: _____

Road Type: □ Interstate □ State Hwy □ County Rd □ State Rd □ City Street □ Other ______________ Description of incident and any other facts (if any) you believe ITRHFM should be aware of: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Documents attached: Death Certificate Police Report Copy of Marriage Certificate Copy of Birth Certificate(s) for Dependent Child(ren) Newspaper Article(s) Other _____________________________________________

*All available pertinent documents should be attached to the submission. It is not required to submit all items.



***************** This Section Only Required For Survivor Fund Monetary Requests ***************** Name For Funds Distribution: _______________________ Relationship to Deceased: ___________________ Address: __________________________________________________________________________________ City: __________________________ State: ________ Zip: __________ Country: ____________________ Phone: ___________________ Fax: ___________________ E-mail: ________________________________ *Distribution should be made to closest living relative 18 or older. Any person other than spouse or dependent children must provide proof of dependency on the deceased to be considered for distribution. ****************************************************************************************** I certify that the above information is true and correct to the best of my knowledge at the time of submission. I understand that review by ITRHFM is confidential, and that its decision is final. I also understand that any award is discretionary, and that meeting the eligibility criteria does not guarantee an award. Should an award be made to me, I agree in advance to allow ITRHFM to list and publish the donation to me and my family. __________________________________________ _________________ Signature of Submitter Date Privacy Information: Submitting information is strictly voluntary. By doing so, you are giving the ITRHFM your permission to use the information for the intended purpose. If you do not want to give the ITRHFM permission to use your information, simply do not provide it. However, not providing certain information may result in the ITRHFM 's inability to provide you with the services you desire.



PROCESSING FORM

SURVIVOR FUND REQUEST FOR MONETARY ASSISTANCE AND

REQUEST FOR INCLUSION ON THE WALL OF THE FALLEN

FOR OFFICE USE ONLY Date Received: ______________________ Applying for: □ Survivor Fund □ Wall of the Fallen □ Both Name of the Deceased: _______________________________________________________ Date of Death: ___________________ City: ________________________ State: ______ Survivor Fund Date Sent to Review Committee: ____________________ Approved Denied Date Sent to Board of Directors: ____________________ Approved Denied Wall of the Fallen Date Sent to Review Committee: ____________________ Approved Denied Date Sent to Board of Directors: ____________________ Approved Denied __________________________________________ _________________ Signature of ITRHFM President Date

ITRHFM-SurvivorFund3315BroadStreetChattanooga,TN37408

NEXTOFKINAFFIDAVIT

Name:__________________________________________________________(LastName,FirstName)

Address:________________________________________________________(Street)

City:___________________________State:__________Zip:____________

RelationshiptoDeceased:__________________________________________

I,______________________________________,declarethat:(FirstName,LastName)

Iamthenextofkinof__________________________________,whodiedonoraboutthe

________dayof___________,20______.

Asthenextofkin,Iamentitledtoreceivetheofferedmonetaryassistancefromthe

SurvivorFund.

________________________________________SignatureofAffiant

______________________Date

Survivor Fund Policies Eligibility Requirements To qualify for a financial assistance award from the ITRHFM Survivor Fund, the deceased must fall into one of the following categories:

• Deceased must have been working as an operator or employee in any capacity with a motor vehicle towing company at the time of the event causing death.

• Deceased must have been working as an operator or employee in any capacity with a motor vehicle repossession company at the time of the event causing death.

• Deceased must have been working as an operator or employee in any capacity with a motor vehicle road service company engaged to work in the same capacity as the towing industry at the time of the event causing death.

Further, the deceased must have been on-duty or performing work directly associated with his/her position at the time of the event. Qualifying Circumstances: • Death that occurs during the act of loading and unloading a motor vehicle, equipment,

material, animal, or non-motor vehicle to be towed or moved on site; • Death that occurs during the act of transporting a motor vehicle, equipment, material, animal,

or non-motor vehicle due to the negligence of another person (i.e.) accident as a result of other persons driving under the influence, careless driving, road rage, etc.);

• Death that occurs during the commission of recovery efforts of a motor vehicle, equipment, material, animal, or non-motor vehicle. Recoveries include, but are not limited to: mountain recoveries, body of water recoveries, culverts, fields, mud, etc.;

• Death that occurs while driving en-route to or from the scene of a call (i.e. accident as a result of another person’s driving under the influence, careless driving, road rage, etc.);

• Death that occurs while performing service calls (i.e. tire change, unlock, jump start, etc.) • Homicide that occurs at the hand of a customer, robber, or passerby while engaged in a call;

Homicide that occurs at the hand of a customer, robber, or passerby while at the home office; • Death that occurs while working in a company office, or at another company operated

location, during the performance of work related duties; • Death that occurs as a result of Infectious Disease that can be proven to have been contracted

during performing duties; • Death that occurs during recovery or cleanup efforts of natural disasters; • Death that occurs days, months or years after disablement or serious injury that was directly

caused by performing duties while on the job (death must be proven to be a direct result of those injuries or disablement).

Excluded Circumstances: • Death that is a direct result of gross negligence on the part of the Tow Operator or employee

including but not limited to: driving under the influence of drugs or alcohol, negligent driving, road rage, in the commission of a felony crime, etc.; Suicide; Homicide; deaths that are not job related, including, but not limited to, domestic homicide, home robbery, etc.;

Additionally, the recipient of the death benefit must meet the following criteria:

• Must be 18 years of age or older. • If only dependent age children are survivors, payment can be made to a trust in their

name if it is established. The ITRHFM will have no part in establishment of these trusts. • Must be directly related to the deceased or spouse (common law accepted where

recognized) of the deceased. Proof of relationship may be required and/or next of kin affidavit.

• Recipient requests for funds must be postmarked within 90 days from the date of death. • The person filling out the request for funds must fill out the application in its entirety and

must include all forms required at the time of submission. Only one award is permitted per death and the ITRHFM is not responsible for additional claims from eligible persons. A reasonable effort will be made in each case to determine eligibility of the recipient and whether there are others eligible who should receive priority. Applications will be processed on a first received, first processed basis. Order of priority for distributions will be basically interpreted as spouse, children, parents and then siblings. Lacking applications from those others, the ITRHFM Survivor Fund committee will vote on funds disbursement and all decisions of the committee are final. Once the vote is complete and payment has been processed, no additional claims or requests for funds associated with a reviewed event will be entertained. Death benefit award shall be a fixed amount to be set annually at the ITRHFM Board of Directors winter meeting. The current benefit amount is $5,000, effective April 8th, 2016. There is also an additional $3,000 benefit available for requests where at the time of death the deceased was a member, or the deceased’s employer was a member at that time, of the International Towing and Recovery Hall of Fame and Museum at any current membership level. Benefit will be set as an amount in United States Dollars and that amount shall also be the maximum payout amount for international claims. International claims will be paid in an amount equal to the same number of currency units within the recipient’s country but will not be paid beyond the maximum US Dollar limit or below an amount equal to two hundred fifty US Dollars. As an example, a payment to the countries below would be as shown based on currency exchange rates on June 9, 2016 as well as the $3,000 death benefit for 2016:

Country ExchangeRate Units Currency ValueinUS Payment(USD)

DollarsAustralia 0.7472380000 3000 Dollar $2,241.71 $2,241.71Brazil 0.2976170000 3000 Real $892.85 $892.85England 1.4453400000 3000 Pound $4,336.02 $3,000.00Indonesia 0.0000755544 3000 Rupiah $0.23 $250.00Japan 0.0093620000 3000 Yen $28.09 $250.00Kuwait 3.3195100000 3000 Dinar $9,958.53 $3,000.00Malaysia 0.2470970000 3000 Ringgit $741.29 $741.29Mexico 0.0552368000 3000 Peso $165.71 $250.00NewZealand 0.7118030000 3000 Dollar $2,135.41 $2,135.41SouthAfrica 0.0675030000 3000 Rand $202.51 $250.00Switzerland 1.0430400000 3000 Franc $3,129.12 $3,000.00

It is beyond the scope of the Survivor Fund to make automatic awards, however committee members may pro-actively contact employers of those killed in the line of service to communicate the availability of benefits. This contact will not be made directly with family members unless contact is first initiated by family members. All applicants will be required to complete an application form to ensure eligibility requirements are met and records are kept appropriately by the ITRHFM. The Survivor Fund committee shall have the right to review any and all exceptions to these guidelines on an individual basis. The approval process for Survivor Fund applications will include the distribution of the submitted materials to the full committee by the museum director which will start a 48-hour clock for each committee member to vote ‘Yes’, ‘No’ or ‘Review’. If all members of the committee vote prior to the 48-hour clock expiration, the majority vote will carry unless prior to the expiration of the 48 hours three members of the committee vote ‘Review’. Should three votes of ‘Review’ occur at any time prior to the end of the 48-hour voting period, the matter will be moved to a review process for full committee review as a group. A call will be scheduled and the majority of the committee members must be present to have a discussion to resolve the matter in Review, including at least two of the persons who voted ‘Review’ in the original round of voting. Once the 48-hour voting clock expires, if a majority of the committee has voted either ‘Yes’ or ‘No’, the vote shall carry and funds disbursement will be settled with that vote count. If there is no committee majority at the end of 48 hours, the voting process will end when a single answer of ‘Yes’ or ‘No’ carries the majority of votes based on the overall size of the committee. Revised - June 28th 2016

Revised - June 28th, 2016

Wall of the Fallen Memorial Policies Eligibility Requirements To qualify for inclusion on The Wall of the Fallen Memorial from the ITRHFM, the deceased must fall into one of the following categories:

• Deceased must have been working as an operator or employee in any capacity with a motor vehicle towing company at the time of the event causing death.

• Deceased must have been working as an operator or employee in any capacity with a motor vehicle repossession company at the time of the event causing death.

• Deceased must have been working as an operator or employee in any capacity with a motor vehicle road service company engaged to work in the same capacity as the towing industry at the time of the event causing death.

Further, the deceased must have been on-duty or performing work directly associated with his/her position at the time of the event. Qualifying Circumstances: • Death that occurs during the act of loading and unloading a motor vehicle, equipment,

material, animal, or non-motor vehicle to be towed or moved on site; • Death that occurs during the act of transporting a motor vehicle, equipment, material, animal,

or non-motor vehicle due to the negligence of another person (i.e.) accident as a result of other persons driving under the influence, careless driving, road rage, etc.);

• Death that occurs during the commission of recovery efforts of a motor vehicle, equipment, material, animal, or non-motor vehicle. Recoveries include, but are not limited to: mountain recoveries, body of water recoveries, culverts, fields, mud, etc.;

• Death that occurs while driving en-route to or from the scene of a call (i.e. accident as a result of another person’s driving under the influence, careless driving, road rage, etc.);

• Death that occurs while performing service calls (i.e. tire change, unlock, jump start, etc.) • Homicide that occurs at the hand of a customer, robber, or passerby while engaged in a call;

Homicide that occurs at the hand of a customer, robber, or passerby while at the home office; • Death that occurs while working in a company office, or at another company operated

location, during the performance of work related duties; • Death that occurs as a result of Infectious Disease that can be proven to have been contracted

during performing duties; • Death that occurs during recovery or cleanup efforts of natural disasters; • Death that occurs days, months or years after disablement or serious injury that was directly

caused by performing duties while on the job (death must be proven to be a direct result of those injuries or disablement).

Excluded Circumstances: • Death that is a direct result of gross negligence on the part of the Tow Operator or employee

including but not limited to: driving under the influence of drugs or alcohol, negligent driving, road rage, in the commission of a felony crime, etc.; Suicide; Homicide; deaths that are not job related, including, but not limited to, domestic homicide, home robbery, etc.; Deaths related to personal health issues and/or natural causes.

SURVIVOR FUND FAQs

Who can raise funds for the Survivor Fund using its name and or logo? The ITRHFM Board of Directors will approve a list annually of those eligible to organize fundraisers for the Survivor Fund using its name and/or logo. These approvals will be provided to the individuals and corporations in written form (the Survivor Fund Fundraising, Name and Logo Usage Permit) and will be good for a period of one year. Should the need arise for an exception on term or to gain approval outside of these sessions, a proposal should be submitted to the Survivor Fund committee for review and upon committee approval this document will be forwarded to the museum president, or his designee, for his determination on Board of Directors approval requirements.

No fundraising activities or events should be held as endorsed or approved by the Survivor Fund without an official Survivor Fund Fundraising, Name and Logo Usage Permit. Each permit will specify the nature of logo and name usage permitted as well as the duration of the permit which will have a maximum time duration of one year.

Is there a time limit associated with submission of collected monies? When approved fundraisers collect monies for the Survivor Fund, these persons or organizations must submit all collected funds to the ITRHFM within sixty (60) days of their collection or within sixty (60) days of the end of specially approved fundraising events that occur over a period of time.

What are the prerequisites for being approved to raise funds for the Survivor Fund? Any person, company, group or organization who wishes to collect funds for the Survivor Fund must first be a metal level supporter of the Survivor Fund. If the person, company, group or organization is not a metal level supporter of the Survivor Fund, they can donate the metal level amount to the Survivor Fund and then deduct the lowest metal level amount (currently Silver at $1,000) from the funds collected in approved projects before making a donation, thus refunding their supporter donation amount. The donation must be made prior to the launch of the fundraiser and must be committed to as a part of the proposal process.

No fundraising opportunities will be considered from persons, groups, companies or organizations who are not either current metal level supporters of the Survivor Fund or who do not make a written commitment to become a metal level supporter to the Survivor Fund as a part of their proposal.

Towing industry, 501(c)(3), non-profit organizations and associations are exempt from the metal level supporter requirement but their fundraising activities for the Survivor Fund must be otherwise proposed and approved.

Who is credited for donations made to the fund when collected by a third party? Whether funds are collected through a pledge drive, auction, direct contact or other method, the allocation of credit for the funds raised for the ITRHFM Survivor Fund shall be given to the person or entity submitting the funds to the museum. There shall not be a duplication of credit for an individual gift. To receive credit for funds given to the Survivor Fund, the donor must send his or her payment to the Survivor Fund directly. Proceeds from auctions and other fundraising events shall be credited to those orchestrating the fundraiser unless otherwise pre-arranged and approved by the Survivor Fund.

What are the qualifications for the Founder’s Club? The Founder’s Club is made up of companies and individuals who have donated $500 or more to the museum’s Survivor Fund. This group is limited to 1,000 members. Founder’s Club members will be recognized in a binder in the museum library as well as on a plaque at the museum. Additionally, the Founder’s Club member

list shall also be posted on the Survivor Fund website with at least annual updates. Founder’s Club members can reach the $500 level through a single gift or may build to Founder’s Club level over the course of numerous gifts. To be eligible for Founder’s Club membership through a series of gifts, donors are encouraged to verify their gifts are categorized together upon receipt by the museum. Members of the Founder’s Club can display the Survivor Fund Founder’s Club logo but cannot use it to raise funds. All logo usage must adhere to the Survivor Fund Licensing Terms and Conditions (a copy will be provided when permission is granted or can be obtained from the committee). What are the qualifications for the Corporate Supporter Recognition Levels? The Survivor Fund offers numerous recognition levels for Corporate Supporters. These levels include Supporter, Silver Supporter, Gold Supporter, Platinum Supporter and Diamond Supporter. Each level requires a different amount of giving and receives different benefits and privileges. These levels are further defined on the Survivor Fund Corporate Support Levels document. Corporate Supporters of the Survivor Fund at all levels will be recognized in a binder in the museum library. Corporate Supporters from the level of Silver Supporter on up will also be recognized on a plaque at the museum. Additionally, the Corporate Supporters member list from the level of Silver Supporter on up shall also be posted on the Survivor Fund website with at least annual updates. Corporate Supporters can reach the various levels through a single gift or may build to each level over the course of numerous gifts. To be eligible for Corporate Supporter metal level recognition through a series of gifts, donors are encouraged to verify their gifts are categorized together upon receipt by the museum. Corporate Supporters can display the Survivor Fund Supporter logo associated with their level but cannot use it to raise funds. All logo usage must adhere to the Survivor Fund Licensing Terms and Conditions (a copy will be provided when permission is granted or can be obtained from the committee). Gifts in kind may be used to reach metal levels in the recognition program but funds collected through fundraising cannot be used for levels beyond Platinum Supporter. What are the qualifications for the Individual and Towing Company Supporter Recognition Levels? The Survivor Fund offers numerous recognition levels for Individual and Towing Company Supporters. These levels include Supporter, Silver Supporter, Gold Supporter, Platinum Supporter and Diamond Supporter. Each level requires a different amount of giving and receives different benefits and privileges. These levels are further defined on the Survivor Fund Towing Company Support Levels document. Individual and Towing Company Supporters of the Survivor Fund at all levels will be recognized in a binder in the museum library. Individual and Towing Company Supporters from the level of Silver Supporter on up will also be recognized on a plaque at the museum. Additionally, the Individual and Towing Company Supporters member list from the level of Silver Supporter on up shall also be posted on the Survivor Fund website with at least annual updates. Individual and Towing Company Supporters can reach the various levels through a single gift or may build to each level over the course of numerous gifts. To be eligible for Individual and Towing Company Supporter metal level recognition through a series of gifts, donors are encouraged to verify their gifts are categorized together upon receipt by the museum. Individual and Towing Company Supporters can display the Survivor Fund Supporter logo associated with their level but cannot use it to raise funds. All logo usage must adhere to the Survivor Fund Licensing Terms and Conditions (a copy will be provided when permission is granted or can be obtained from the committee). Gifts in kind may be used to reach metal levels in the recognition program but funds collected through fundraising cannot be used for levels beyond Platinum Supporter.

1. Recycle your old cell phones2. Give back to the industry by supporting the Survivor Fund and the International Towing and Recovery Hall of Fame Museum

It is simple:1. Drop your old cell phones in a box (They do not have to be Sprint or Nextel phones)2. Print and attach the prepaid shipping label (it’s free!)3. Mail the box

Sprint will:1. Open the box2. Determine the types of phones and the current value in the program ($1 - $400)3. Provide a monthly report and a check for the program

Background

developed this program as a way to repurpose or recycle these unwanted devices while providing an incentive for sending them in.

and program rules. Their device values are based on current need—supply and demand. These values are published online and update regularly.

Sprint repurposes or recycles all of the devices that are sent back under this program. Even when devices have no incentive value, they

Survivor Fund for hundreds of eligible wireless devices—no matter what carrier they’re from.

electronic waste disposal possible.

• Sprint gives full credit regardless to the condition of the device. The device doesn’t have to power on or include battery.• Sprint does not give credit for accessories; however they will be glad to properly recycle these items.• Sprint provides credit for over 900 SKU numbers. If the model is not included in the SKU list, they pay $1.00 per unit.• Sprint pays for domestic shipping only. International shipping is too expensive for them to absorb the cost.• If the monthly collection doesn’t exceed $10, the money will be withheld until the total is greater than $10. This is due to the administrative cost of issuing a check.

Clear out your shelves and drawers of old phones and help the Survivor Fund and the International Towing and Recovery Hall of Fame Museum.

There are some unique quali�cations to participate in the program and towPartners meets these requirements. In doing so, towPartners has agreed to donate 100% of the proceeds of the program to the Survivor Fund and the International Towing and Recovery Hall of Fame and Museum. Sprint is expected to report on monies earned and to provide payment on a monthly basis. These payments will be processed by towPartners in a timely manner and then paid to the Survivor Fund and Museum.