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Name*

First Name Last Name

Association/ Department Name:*

Cell Phone*

Work Phone

Is this a critical Incident?*

Yes
No

FOR CRITICAL INCIDENTS, PLEASE CALL THE LDF AT 209-774-5600 FOR IMMEDIATE ASSISTANCE.

*What is a critical incident: A critical incident for purposes of this policy is a situation where a Participant is involved in an incident involving death or serious injury, including but not limited to situations involving injury or death while in custody, during a pursuit, or after a discharge of a weapon. Select "No" to submit a non-critical incident claim.

Address*

Street Address City State ZIP Code

Email*

Confirm Personal Email*

“I hereby authorize the Legal Defense Fund (LDF) to use the instant email address, which I have provided to LDF, as a method of communication for all future communications between myself and LDF. I acknowledge that information regarding my LDF coverage and legal representation will be sent to this email address. During my request for coverage, I was fully informed of the importance of using a personal email account and not a work email account.”

Please note that the consent provided is only for this LDF matter. If you are notified of a separate investigation, please call the LDF office at (888) 556-5631 or visit our website (www.poracldf.org), to request additional coverage. Please also contact us immediately if you have any questions regarding the above consent, prior to responding with “Confirmed”.

Finally, please contact us immediately if your email address changes in the future, or if you request LDF discontinue communicating with you via this email address.

(LDF assures you that your email address will remain confidential and will not be shared with anyone outside of the administrative office, without your consent to disclose.)

Consent to receive correspondence from LDF*

Yes
No

Age*

Rank*

Years in Dept*

Years as Peace Officer*

Rank Status*

Permanent
Probation

Claim Type(s) Check all that Apply:

Administrative

Civil

Please have a copy of your Summons and Complaint ready, you will be required to email this to your case coordinator.

Criminal

Allegations

Please do not cite department policy numbers; laymans' terms

Date alleged incident took place

Date Unknown

Your status during the incident

On-Duty
Off-Duty

Agreement

A Legal Case Coordinator will call you at the number provided before the end of the day to open a claim. The Intake process takes 5-6 minutes and is conducted over the phone.

Please note that all requests filled out and submitted at 4pm on a weekday may result in a call back the next business day. If a claim is submitted on a weekend or recognized holiday, you will receive a call back from a case coordinator the next business day.

For a critical incident that requires immediate legal assistance, please call the LDF office at 209-774-5600.

I acknowledge that I have read and understand all the information in this form.*

I acknowledge that the information that I have provided above is correct*

I acknowledge that completion of this form does not mean that I have LDF coverage for my legal representation request. I understand that unless I have spoken with an LDF Case Coordinator, a case number has been issued and I have been referred to a designated law firm for legal representation, LDF coverage has not been provided.*

Privacy Policy

Every step is taken to protect your privacy. This information is kept secure within the firm software programs that are protected by password in our system which is further protected by extensive firewalls.

All conversations and correspondence with the Legal Defense Fund is confidential.

I acknowledge that I have read the above privacy information provided by PORAC Legal Defense Fund regarding my personal information.*

Signature*

Date*

Start A Claim

PORAC LEGAL DEFENSE FUND ONLINE INTAKE CLAIM

Intake Claim

Claim Type(s) Check all that Apply:

Agreement

Privacy Policy