Line of Duty Injury Assistance Request

Financial assistance is provided to the families of public safety officers and firefighters upon serious injury.  Assistance is extended to volunteer and/or reserve officers/firefighters only when the incident occurs while he/she is on duty. To request assistance for a public safety officer or firefighter, the appropriate form must be completed by a supervisor or by human resource personnel. Potential beneficiaries are not authorized to submit requests. If you have questions, please feel free to call our office at (602) 362-8416. Please utilize this form for the initial injury request or the continuance request of an already submitted injury. 

Please use the links to the right to fill out the appropriate request form. If you are not contacted by a 100 Club of Arizona representative within 24 hours after submitting your request, please call our office at (602) 362-8416 to verify that your paperwork has been received.

Funding provided:

LINE OF DUTY INJURY (LODI)
$500 per month 

ON DUTY INJURY
$500 one-time assistance