LEGAL DEFENSE FUND
APPLICATION FOR PARTICIPATION
RESERVE ASSOCIATIONS
Name of Association: _____________________________________________________________________
Mailing Address: _____________________________________________________________________
Authorized Representative: _____________________________________________________________________
Home Phone : (___) __________________________Business Phone: (___) ______________________________
Total Number of Members in Association: ______________________
Number of Members Participating in LDF:__________________
| LDF Plan Requested: IV | Optional | ____Enhanced Limited Administrative Coverage |
(Reserve Peace Officers may be enrolled
only in Benefit Plan IV (limited administrative coverage) and may elect the
enhanced reserve officer option with or without the Field Representative option.
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 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 |
FOR DHS/POLICE BENEFITS ADMINISTRATION USE ONLY:
|