Treehouse - Request for Auto Insurance

What is your relationship to the youth driver?*

Select the option that best describes your relationship with the youth.

Your Name:*

Person completing this application.

First and Last Name

Your Phone:*

Your Email:*

Youth Driver's Name:*

Youth/Driver needing assistance

First and Last Name

Youth Driver's Date of Birth:*

Youth's Driver's License Number:*

Youth drivers must have their driver’s license to be eligible for auto insurance funding. This is the driver's Washington State DOL PIC or WDL number found on the Identification card.

Youth Driver's Phone:*

If the participant does not have a personal phone, please input the number for the person who will have the most contact with them.

Youth Driver's Email:*

Must be participant's unique email address.

Youth Driver's Mailing Address:*

Street Address City, State, Zip Code

Does the youth currently qualify as one of the following?*

Youth must meet one of the following criteria to be eligible for Treehouse's Driver's Assistance program.

Foster Care - Washington State Dependent
Foster Care - In-home Trial Return
Extended Foster Care - Foster to 21
Tribal Jurisdiction - Indian Child Welfare (ICW)

Name of Youth's Social Worker:*

First and Last Name

Social Worker Email:*

Social Worker Phone:

Youth's Tribal Association:

Youth Driver's Tribal Contact:*

First and Last Name

Tribal Contact Email:*

Tribal Contact Phone:*

Is the youth driver currently working with an Independent Living Case Manager?

Yes
No

Organization associated with Independent Living Program:

Name of Independent Living Case Manager:*

First and Last Name

Independent Living Case Manager Email:*

Independent Living Case Manager Phone:

Caregiver's Name:*

Write N/A if youth driver is on individual insurance plan.

First and Last Name

Caregiver Email:*

Write N/A if youth driver is on individual insurance plan.

Caregiver Phone:

Is the youth driver currently on an active auto insurance policy?*

Yes
No

What type of auto insurance policy does the youth driver have?*

Youth is on their own individual policy
Youth is on a joint or shared policy

What type of auto insurance policy will the youth driver have?*

Youth will be added to an existing auto policy
Youth needs their own auto policy (new policy)

What vehicle does the youth drive?*

Please provide the make and/or model of the vehicle.

Additional Policy Holder's Name:*

Who is the youth sharing this joint auto insurance policy with?

First and Last Name

Additional Policy Holder's Email:*

Additional Policy Holder's Phone:

Please upload an auto insurance quote from an insurance agent or broker that includes the youth as a driver.*

The quote must include contact information for the insurance agent or broker.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 2.

Please upload the insurance declaration page.*

This document should contain a policy number, policy period dates, cost of insurance premium, vehicles and all drivers listed on it.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 2.

What type of payment are you requesting?*

For joint policies, we can either provide reimbursements to the policy holder or pay a single payment to the insurance company directly. If you receive an auto-pay discount, you may want to consider reimbursement.

Direct payment to insurance company
Reimbursement to policy holder for insurance already paid for

Preferred reimbursement method*

Please select your preferred payment option. Treehouse prefers to utilize electronic payment methods whenever possible.

PayPal handle, email, and/or phone number*

Please enter the handle for your PayPal account (for example, @treehouse), or enter your email or phone number connected to your account.

Should the check be mailed to someone other than the youth?*

Yes
No

Please provide the name of who to send it to and their mailing address. Include First and Last Name, Street Address, Apartment or Suite, City, State, and ZIP code.

Mail To: Name*

Mail To: Mailing Address*

Street Address City, State, Zip Code

We are able to pay up to 6 months at a time toward auto insurance premiums. Are you requesting a single month payment or a 6 month payment toward your insurance premium?*

Note: Requests are granted on a first-come first-served basis. Monthly payment is not guaranteed and participants will need to fill out this application each time a new payment is needed.

Single Month Payment
6 Month Payment

Hidden

For joint policies, we can either provide reimbursements to the policy holder or pay a single payment to the insurance company directly. Are you requesting a single month payment or a reimbursement toward your insurance premium?*

Requests are granted on a first-come first-served basis. Monthly payment is not guaranteed and participants will need to fill out this application each time a new payment is needed.

Single Month Payment
Reimbursement to Policy Owner

Total Amount Due:*

Payment Due Date

Treehouse provides one year of AAA Premier Membership for those receiving auto insurance assistance. Would you like to receive AAA?*

Yes
No

Upload Receipt:*

(Please provide a receipt for services paid; ex. printed receipt, redacted credit/debit statement.)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 3.

Treehouse Driver's Assistance Release of Information*

Driver’s Assistance is pleased to provide financial support for your driving goals. In order to successfully process payments and as a condition of enrollment, Treehouse requests permission to communicate, and request documents and details from your insurance company. Please review and ensure that all the information entered above is correct.

I understand that Treehouse is only accessing information for the purpose of making payments and any data collected will be used solely for Treehouse's Driver’s Assistance Program.
I accept and agree to all of the above and that I have reviewed the information entered above and certify that all the above is correct.

We would love to hear from you!

Please indicate below if you are willing to receive one to two surveys over the next 6 to 12 months. Your participation helps us understand how we can better support youth experiencing foster care.

Yes, send me the surveys!

Auto Insurance

Request for Auto Insurance Funding

DA Auto Insurance Request 2021