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Line of Duty Injury

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"The future of my career as well as the quality of my mobility was uncertain…I want to thank everyone at the 100 Club for lessening the burdensome load." - Phillip Bidwell, Senior Patrol Agent, US Border Patrol

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:

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