Intake Form Business Consulting - DOC by rar12290


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									                     GCCF Claim Technical Assistance Intake Form
                           Seedco Financial Southeast Louisiana Fisheries Assistance Center
                  Phone: 504.392.2454. Fax: 504.392.2456. Address: 212 Avenue G, Belle Chasse, LA 70037
Myla Poree, Program Coordinator: | Dustin Ridener, Intake Coordinator,

    Name:                                                    Phone:

    Business Legal Name:                                     DBA or Vessel Name:

    Business Street Address:

    City:                                  State:            Zip:                      Parish:
    Home Street Address:
    City:                                  State:            Zip:                      Parish:

    Email Address:                                           Fax Number:

    Have you filed a claim?               Yes        No      Tax ID #
    Was your claim denied?                Yes        No      Claim Number:
    Reason for denial:                                        Date Filed:
    Claim Type:
        Bodily Injury           Subsistence           Lost Income           Property Damage
    Employment Status:         Employer         Employee      Have Employees Filed Claims?          Yes         No
    Business Type/Profession:
                                                              Number of Current Employees:
    Years in Business:
                                                              Number of Employees Last Year:
    Previous Year’s Revenue/Budget: $                        Currently open and operating?           Yes        No

    Have you received claim payments?                         Do you have a Vessel of Opportunity Contract?
        Yes           No                                          Yes            No
    Total Payments Received:
        Full      Partial     Wait time:                    Total Payments Received:
    Have you hired an attorney?         Yes            No   Reason:    Claims assistance         Filing a lawsuit
    Do you have any debts and/or loans that you are having challenges with paying?

    Do you have health insurance or other health care?         Yes          No
    I hereby authorize Seedco Financial to release the above information concerning claims submitted to Gulf Coast
    Claims Facility to its funding partners, and to its technical assistance partner LSBDC. No individual identifiable
 information will be shared with out prior consent.

 Client Signature:                                                                 Date:

 Intake Date:                                           Referral Date:
 Referral Partner:    South Louisiana Economic Council        Coastal Communities Consulting    VoA     ASI
     MQVNCDC           Catholic Charities      GNO, Inc.       Literacy Alliance   Operation Hope     VIET
    Terrebonne Economic Dev. Authority          Seedco Financial Services     LSBDC
 Form Prepared By:                                       Intermediary:

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