Group Application
Lodge/Group Information
Lodge Name
Lodge Number
Primary Contact First Name*
Primary Contact Last Name*
Address (for mailing packages
and/or invoices)
Zip Code
*NOTE - Should the primary contact change it is the responsbility of the Lodge/Group to notify the Legal Defense Plan of the change including address and phone number.
Coverage Options
Administrative, Civil, Criminal and Administrative Off-Duty
Annual Rate: $300.00 per participant
Civil and Criminal
Annual Rate: $64.00 per participant
Payment Method
Member List
To add a new row, press Tab or Enter on your keyboard when you are in the Employer cell for the last row in the grid. Rows will only be validated if there is content in any one of the four cells in the row. To delete a row, click on the red X at the end in the last cell.
FOP ID Number SSN (Last Four Digits) Last Name, First Name Middle Initial Employer
Signature Date Signed Click here to choose a date.
Coverage effective dates are the first day after application approved and payment received by Hylant.
PLEASE MAKE CERTAIN THE MEMBER LIST IS COMPLETE AND ACCURATE. Applications not fully and accurately completed may result in ineligibility for, and non-payment of benefits.
Any person who is subsequently determined not eligible for benefits as of the date a claim arises, will not receive payment of benefits.