Blank LPP Claims Form | Neptune Township PBA Local #74

Back to forms

NJ STATE PBA LPP CLAIMS FORM Must be completely filled out and signed by the State Delegate

Name of Member:

Member Telephone #:

Member's Social Security Number:

Local Name, Number & Municipality:

Date of Incident:

Type of Claim:

Synopsis of Allegations:

Proposed Penalty:

Negotiations/Results with Agency:

Member must provide this claim form completely filled out and signed by their State Delegate to their attorney along with the charging documents/target letter. Claims will not be opened with an incomplete claim form.

I affirm that I have given a completed copy of this form to the President of my Local.

State Delegate's Name:

Date Completed:

State Delegate's Signature:

Note: State Delegate must confirm that Attorney is an active approved member of the NJSPBA LPP.

Attorney's Signature:Date Received:

Attorney to file initial copy of claim form within 30 days of receipt for validation purposes. LPP coverage is not confirmed until written approval is received from NJSPBA. Attorney is not authorized to charge a retainer for claims covered under the Legal Protection Plan.