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"Thanks to the 100 Club’s efforts, I now have peace of mind that our officers are supported by the best equipment available to them." - Lawrence Rodriguez -- Tolleson City Chief of Police and Safety Enhancement Stipend recipient.

Line of Duty Injury
Request Form for Potential Benefits

To request benefits , fill out the following form as complete as possible.

Date of Incident:

Line of Duty:

Yes No

Years of Service:

Personal Information of Injured Party

First Name:

Last Name:

Date of Birth:

Title/Position:

Spouse
(If applicable)

First Name:

Last Name:

Date of Birth:

Contact Information for Injured Party

Address:

Address 2:

City:

State:

Zip:

Home Phone:

Mobile Phone:

Other Phone:

Email Address:

Make Benefit Check To:

Dependents
(Other than spouse)

Dependent 1 Name:

Dependent 1 Date of Birth:

Dependent 2 Name:

Dependent 2 Date of Birth:

Dependent 3 Name:

Dependent 3 Date of Birth:

Dependent 4 Name:

Dependent 4 Date of Birth:

Information Provided By:

First Name:

Last Name:

Title/Position:

Office Phone:

Mobile Phone:

Fax:

Email:

Department/Agency:

Address:

City:

State:

Zip:

Incident Detail: (Provide who, what, when, where, how, reports, articles, if available.)

Surgery Involved:

Yes No

Estimated Recovery Time:

Enter the following code.

When you click the button below your benefits request will be emailed to the 100 Club Office.

100 Club Sponsors

Benefits Forms

Testimonials

Line of Duty Injury Request Form for Potential Benefits

Line of Duty Injury
Request Form for Potential Benefits