The Relief

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

NOTE: Forms must be downloaded and completed on your desktop.

Designation of Beneficiary ONLINE

Designation of Beneficiary

Update Form ONLINE

Change of Address
Application for Emergency Advancement
Application for Financial Assistance
Application Trust Preparation Advancement
Retired Firefighter Sick and Injury Application
Active Firefighter Sick and Injury Application
NIOD Statement
Cemetery Plot Application

Firefighter Event Reimbursement Form

Medical Forms

Disabled Dependent Certification

Flu Vaccine Claim From

Medical Claim Form and Authorization

Medical Plan Enrollment / Change Form

Prescriptions: Express Scripts Home Delivery (Mail) Order Form