LEGAL DEFENSE FUND
APPLICATION FOR PARTICIPATION

Name of Association:  ___________________________________________________________________________

Mailing Address:  _______________________________________________________________________________

Authorized Representative:  _______________________________________________________________________

Home Phone : (___) __________________________Business Phone: (___) ________________________________

Total Number of Members in Association (Excluding Reserves* and Retirees): ______________________

*(A separate Application must be completed for Reserve Peace Officers. Reserve Peace Officers may be enrolled only in Benefit Plan IV and the enhanced reserve officer option (limited administrative coverage).

Number of Members Participating in LDF:__________________

LDF Plan Requested:_____________

Payment Option: ____No cost containment Other Options ____Enhanced Non-Scope Option
____Co-Payment        (Plan I)
____Deductible

       
____Both Co-Payment and Deductible

Date you would like LDF Coverage to Begin: ___________________________________________________

The undersigned acknowledges that he or she has received a copy of the Plan Document of the PORAC Legal Defense Fund, that he or she has read Article II thereof which sets forth the requirements for participation in the Fund, and certifies that the Association will make required contributions on behalf of more than 50% of its members. The LDF Board of Trustees or the Legal Administrator shall review each application to insure that the Member Association satisfies the eligibility policies adopted by the Board.

Signature of Authorized Representative:  __________________________________________________________

Title: __________________________________________Date:_________________________________________

Please return application, a list of Association members who have elected to participate in the Legal Defense Fund with their addresses, and the first calendar quarter contributions (pro-rated if joining in mid-quarter) to:

Legal Defense Fund, c/o DHS/Police Benefits Administration, P.O. Box 2487, Stockton, CA 95201

To enroll in the Legal Defense Fund, you must be a member of one of the following organizations:
CALIFORNIA: PORAC @ 1-800-93-PORAC NEVADA: PORAN @ 1-800-93-PORAC ARIZONA: APA @ 1-602-246-7869
OREGON: OCPA @ 1-514-672-7719
 
 FOR DHS/POLICE BENEFITS ADMINISTRATION USE ONLY:
 Postmark Date:  ____________________      Amount Enclosed:  __________________
 Effective Date: ______________________      Confirmed:   ________________________
 Assn. No:  _________________________      LDF Assn. No.:       __________________
 Plan: ___________     Rate: ___________      Effective Date:         __________________
 Date Entered:  ______________________      Date Billed:   ________________________