All Forms

Below is a list of downloadable forms for our members’ convenience. Unless otherwise stated on the form, these forms must be mailed to:


Los Angeles Firemen’s Relief Association
P. O. Box 41903
Los Angeles, CA 90041
or faxed to (323) 259-5290 / DO NOT send any medical personal health information (PHI)

FAX Numbers

• Add/Drop Dependent (323) 259-5297
• Flu Vaccine Claim Form  (559) 499-2464 or (323) 259-5295
  
• Green Form / Unprocessed Medical Expenses Claim Form (CA) (559) 499-2464 or (323) 259-5295

Relief Forms

• Designation Of Beneficiary: Online / Download, Print and Mail 
• Update Form: Download, Print and Mail
• Change Of Address Form: Download, Print and Mail or Email
• Application For Emergency Advancement
• Application For Financial Assistance
• Application For Trust Preparation Advancement
• Retired firefighter Sick or Injury Application
• Active firefighter Sick or Injury Application
• NIOD Statement

Medical Forms

• Medical Plan Enrollment Form
• Add/Drop Dependent
• Flu Vaccine Claim Form
• Disabled Dependent Certification
• Unprocessed Medical Expenses Claim Form For CA Members (Green Form)
• Prescriptions: Express Scripts Home Delivery (Mail) Order Form