Tell Us About Yourself

We need to collect some basic information about you to start the enrollment process.

iName *

iBirthdate *

iSSN *

iHome Address *

iPrimary Phone

iAlternate Phone

iFOP Member # *

iFOP Lodge *

iBroker Agent ID

Create Account

Use your email address to sign into the member portal after you have enrolled.

iEmail Address *

iConfirm Email *

iPassword *

iConfirm Password *

Member Name

DOB

Resident

Email

Member ID

Group 1234567

Coverage

Accident + Short-Term Disability Coverage

Accident + Short-Term Disability Insurance

Accident Insurance pays a cash benefit if you or your dependents are injured as part of a covered accident. Benefits are paid directly to you, so you can use the money however you need to.
Learn More...

Critical Illness

With critical illness insurance, you’ll receive a lump-sum cash payment if you or an eligible member are diagnosed with a covered illness.
Learn More...

$ payout   -   $ per month
$ payout   -   $ per month

Member Name

DOB

Resident

Email

Member IDGroup 1234567

Billing Statement

Accident + Short Term Disability Plan $0.00
Critical Illness Plan $0.00
Sub Total $0.00
Administration Fees $0.00
Total $0.00

* Effective date will be determined upon approval

ACH Payment Information

iBank Name *

iAccount Type *

iBank Address *

I authorize premium for the insurance products and fees for the non-insurance products that I have selected to be charged to my bank account, credit or debit card upon enrollment, and then automatically on the effective date of each month thereafter. By clicking submit, I acknowledge that I have read, understand and agree to the terms of coverage, and that the insurance coverage elected is not traditional health insurance or major medical coverage, and it is not designed as a substitute for traditional health insurance or major medical coverage. WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INOFMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

Member Name

DOB

Resident

Email

Member IDGroup 1234567

Billing Statement

Accident + Short Term Disability Plan $0.00
Critical Illness Plan $0.00
Sub Total $0.00
Administration Fees $0.00
Total $0.00

* Effective date will be determined upon approval

Please verify your information below before completing your purchase.

Billing Statement

Accident + Short Term Disability Plan $0.00
Critical Illness Plan $0.00
Sub Total $0.00
Administration Fees $0.00
Total $0.00

* Effective date will be determined upon approval

Member Name

DOB

Resident

Email

Member IDGroup 1234567

Bank Name
Account # ending in 1234

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and