First Name
Last Name
Address
City
State	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
Zip Code
Phone
SSN (Last Four Digits)
E-mail

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

Active Annual Rate: $50.00

Retired Annual Rate: $50.00

If active, please provide the name of your employer.
Employer Name

Payment Method

Check Credit Card

Signature Date Signed

Notes

Coverage effective dates are the first day after application 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 an 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 submitting this form you are certifying that you meet all of the requirements set forth in LEOSA. If you are currently employed as a law enforcement officer by a governmental agency, LEOSA requires, among other things, that you must have powers of arrest, be authorized by the agency to carry a firearm and have met all agency standards to qualify in the use of a firearm. If you are retired as a law enforcement officer from a public agency, LEOSA requires, among other things, that you must have 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 MUST HAVE MET WITHIN THE MOST RECENT 12 MONTHS THE STANDARDS FOR QUALIFICATION IN FIREARMS for active law enforcement officers as determined by your previous agency or your state; if your state has not established standards, you may qualify through any law enforcement agency in the state or by meeting standards of a certified firearms instructor in your state. Not fulfilling these requirements and others set forth by LEOSA will result in no coverage.