If you are interested in joining the Legal Aid Plan, or want additional information about the plan, please print this form, complete in full, and send to:
Fraternal Order of Police
Tennessee State Lodge
P O Box 8
Tipton, TN 38071-0008
1-800-783-7591
901-331-4016 (after hours help)
APPLICATION TO THE TENNESSEE STATE LODGE LEGAL AID PLAN
____ $48.00 fee enclosed
____ Send me a copy of the complete plan document
Name:________________________________________________________
Address:______________________________________________________
City:_________________________________________________________
State:_______________Zip:______________________________________
Home Phone: (___) _____________Work Phone: (___) ________________
Lodge Name & Number:_________________________________________
Social Security Number:__________________________________________
Employer:_____________________________________________________
I hereby apply for enrollment in Tennessee State Lodge Legal Aid Plan. I agree to abide by all of the terms and conditions thereof. I understand that my coverage will not be effective until the receipt of my payment to the plan and acceptance by Legal Aid Committee of the Tennessee State Lodge of the Fraternal Order of Police. To my knowledge, I am not presently named in any suits, actions, or proceedings, nor under investigation for a duty-related incident, except for the following (please use an 8 1/2" x 11" paper and attach to this application).
Date:________________________
Signature:_____________________
Note: The information contained in this Web Site is not the actual plan description. In all cases, the actual Plan description supersedes the information provided on this site. To determine the coverage of this plan, please refer to the actual Plan description available from the office of the Tennessee State Lodge. Because this plan is new and a important project by the Tennessee State Lodge, the Lodge reserves the right to amend the Plan based upon the experience and actual or projected demand.