FOP Application

Lodge/Group Information
Lodge Name
Lodge Number
Primary Contact First Name*
Primary Contact Last Name*
Address (for mailing packages and/or invoices)
City
State
Zip Code
Phone
Fax
E-mail

*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


Supplemental Questions
Name of previous/current plan
Address of previous/current plan
City
State
Zip Code
Date group coverage under plan began
Is coverage currently in effect?
If not, date coverage ended
Did coverage include defense or administrative disciplinary proceedings?
Did coverage include defense of civil and criminal proceedings and lawsuits?
Have all known, existing incidents and claims been reported to the most recent plan?
If not, how many unreported claims exist?
Please describe all such unreported claims

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

Notes

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.

Payment Options
Quote provided by FOP Legal Defense Plan upon application submission.