FOP Application

First Name
Last Name
Address
City
State
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 .

By completing this application, I certify that I am currently employed by a

	federal, state or local law enforcement agency.
	local government enforcement entity operated by a private college/university, private railroad or Native American tribal government.

Please provide the name and address of the federal, state or local government law enforcement agency.
Name of Employer
Address
City
State
Zip Code

Please provide the name and address of the local government enforcement entity operated by a private college/university, private railroad or Native American Tribal government.
Name of Employer
Address
City
State
Zip Code
Name of private college/university, private railroad or tribal government

Payment Method

Please provide the name, address and telephone number of the agency that has certified you to carry firearms, and the specific title of the certification, including POST and CPOST certification.
Name of Agency
Specific Title of Certification
Address
City
State
Zip Code
Phone Number

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 employed by a federal, state, local government law enforcement agency or employed by a law enforcement entity operated by a private college/university, private railroad or Native American tribal government and be an FOP member in good standing to participate in this plan on an individual basis 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.