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Get fop claim form

Work: May we contact you at work? Yes : Cell: No: 4. Social Security No. SSN AL 5. Lodge / State # 6. Law enforcement employer and employer's address, city, state, zip 7. Date of incident: resulting in (or which may result in) administrative discipline or lawsuit? Date: 8. Specifically describe the incident leading up to the claim presented for review. 9. Specifically describe any administrative charges or discipline: 10. Lawsuit filed? Yes: No: *( CONTINUE ON SEPARATE PAGE ) (CONT.

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