This form is for employers to refer their employees for assistance. Emergency relief assistance may be available to workers who have lost employment due to employer's loss of their home or business because of the January 2025 wildfires. (Please fill out a separate form for each employee).
Employer Information
Your First / Last name
Your Phone number
Your Email address
Your Affected Property Address
Your status
Explain:
Are you continuing to pay your employee? If so, how much for how long?
If your home was impacted by the fires you have insurance information that you can share, please do so below.
Your Insurance Claim Information
Insurance Company: (Optional)
Insurance Company Phone Number: (Optional)
Claim #: (Optional)
OR
Please upload a copy of your insurance claim information
Impacted Employee Information:
Employee Full Name
Employee Address
Employee Phone number
Employee Email address
Please describe your employee's job and length of employment :
How much did you pay them (per hour & per month)? What type of work did this employee do? How long did they work for you?
How did you hear about us?
Verification