Policy Type

New Renewal

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)
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 or part-time peace officer?

Yes No

Limit Options and Annual Premium

Limit

$100,000 $250,000 $500,000 $1,000,000

	Please select one of the following:
	I would like coverage only for the remainder of this term, up to April 1st of
	I would like to renew coverage, beginning or after April 1st of

Coverage effective  1,  to January February March April May June July August September October November December-->  1, 

FOP Member: $0.00

Non-FOP Member: $0.00

Payment Method

Check Credit Card/ACH

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

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 lynn.young@hylant.com