Moonlighting Application
Policy Type
First Name
Last Name
Address
City
State
Zip Code
Phone
SSN (Last Four Digits)
Law Enforcement Agency
Email Address
If all of the following 3 fields are left blank, non-member status will be applied.

Lodge Name
Lodge Number
FOP Member Number
Are you a full-time peace officer?
(Coverage is only available to currently full-time Peace Officers.)

Limit Options and Annual Premium

Limit
$100,000
$250,000
$500,000

Coverage effective  1 to  1, 

FOP Member:  Non-FOP Member: 


Payment Method
Estimate number of moonlighting jobs per year
Estimate number of hours per year

By completing this application, I agree that the information provided is factual, and that any misrepresentation of any material fact constitutes grounds for termination or denial of coverage. I also agree that all Off Duty Work is departmentally approved and authorized prior to my engagement in any Off Duty jobs.
Signature Date Signed Click here to choose a date.
Notes
Coverage effective dates are the first day 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.
The Moonlighting Liability Program is not a plan offered or covered by FOP Legal Defense Plan, Inc. The Moonlighting Program is offered and insured by an outside independent insurance company and is endorsed by The Grand Lodge FOP.
All necessary documentation will be sent in the order received, please allow up to 72 business hours before contacting Lynn Young at 419-724-8726.