Application for United/Lane Employee Assistance

Before starting the application, please gather the following documentation that you will need to upload into this form:
  1. Your photo ID
  2. Proof of prior employment at United/Lane (e.g., last pay stub, direct deposit, unemployment registration)
  3. The electric bill for which you are applying for assistance

Personal Information

Please answer these questions for yourself or the person requesting the assistance.
Name(Required)
Spouse/Partner Name, if applicable
Address(Required)
Date

Documentation

Uploaded files must be less than 8 MB. If your file is too large to attach, you can try a couple of things: 1. Save the document as a lower-quality or low-resolution file 2. If the file is a photo, try cropping it to make the overall file smaller. If you still have trouble, please call us at 662-841-9133.
Drop files here or
Max. file size: 8 MB.
    Drop files here or
    Max. file size: 8 MB.
      Even if you do not have a current balance due, please upload your most recent electric bill.
      Drop files here or
      Max. file size: 8 MB.

        Confirmation

        Consent and Confirmation(Required)