To request assistance for a public safety officer or firefighter, the appropriate form must be completed by a supervisor or human resource personnel. Potential Beneficiaries are not authorized to submit requests.
For line of duty injuries there are 2 different forms, please select the appropriate form.
Benefit #1 is for a first time Beneficiary who has not received any prior benefit.
Benefit #2 is for a Beneficiary that has already received the initial benefit and is now eligible for subsequent benefits.
** Please select the appropriate form. **
Line of Duty Injury Benefit Request Forms
- Benefit #1 Initial Request Download (PDF) Version
- Benefit #2 - 12 Subsequent Request Download (PDF) Version
Line of Duty Death / Non-Line of Duty Death Benefit Request Forms
Benefit Questions, E-mail: info@100club.org