First Name
Last Name
Address
City
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I am an FOP member in good standing. My FOP Member Number is , and I belong to Lodge Name and No. in the state of Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Guam Northern Mariana Islands Puerto Rico United States Virgin Islands.

Employment Status

Retired Annual Rate: $75.00

Payment Method

Check Credit Card

Signature Date Signed

Notes

Coverage effective dates are the first day after the application is approved and payment received by Hylant.  Applications not fully and accurately completed may result in ineligibility for, and non-payment of benefits.  You must be a FOP member in good standing to participate and be eligible for benefits.

Any person who is subsequently determined not to be eligible to participate or to receive benefits as of the date a claim arises, will not receive payment of benefits. By signing below, you are certifying that you are legally carrying a concealed firearm within your state under the state’s qualifications or meet all of the requirements set forth in LEOSA.  In order to qualify, you must be a retired law enforcement officer from a public agency, who among other things, had powers of arrest while employed, must have retired in good standing after a minimum of 10 years of service (or have a duty disability), and you must be legally carrying a concealed firearm at the time of the incident giving rise to any claim.

Further, by signing below, you are certifying that you agree to the terms of the Plan Description found in www.foplegal.com.