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

Designation of Beneficiary ONLINE

Designation of BeneficiaryDownload
Update FormDownload
Change of AddressDownload
Application for Emergency AdvancementDownload
Application for Financial AssistanceDownload
Application Trust Preparation AdvancementDownload
Retired Firefighter Sick and Injury ApplicationDownload
Active Firefighter Sick and Injury ApplicationDownload
NIOD StatementDownload
Cemetery Plot ApplicationDownload

Medical Forms

Medical Plan Enrollment/Change FormDownload
Flu Vaccine Claim FormDownload
Disabled Dependent CertificationDownload
Medical Claim Form and Authorization (Green Form)Download
Prescriptions: Express Scripts Home Delivery (Mail) Order FormDownload