New Members: Please complete the forms that are *below.
New coverages include:
$10,000 Basic Life $10,000 Accidental Death and Dismemberment
$10,000 Covered Activity Accidental Death and Dismemberment (Line of Duty)
Accidental Burn and Disfigurement
Burial and Cremation Benefit
Terminal Illness Accelerated Death Benefit
Waiver of Premium
Print and sign or digitally sign and email and return form to Christa Brown, firstname.lastname@example.org.
If you have any questions please call 540-422-8804.
Transfer Membership: Please complete the forms that are **below
Vol. Members Move/Change Agency Tutorial (Please follow these steps)
In accordance with Operating Procedure 703, Accident, Injury and Property Loss Reporting, see the guidance below for reporting job related injuries/illnesses, vehicle accidents, and property damage.
It is the responsibility of the employee to report any injury/illness, vehicle accident, or property damage incurred while performing their official duties. The reporting of such incidents shall be done immediately or as soon as practical to their immediate supervisor.
DO NOT delay medical treatment if necessary. If you believe there was a risk of exposure follow exposure control plan and contact Exposure Control Officer.
Employee: After the supervisor is notified, the employee and supervisor (together if possible) will access the Industry Safe reporting database via the public web form:
The employee needs to fill out the basic information module and attach any photos or memos. Be accurate and descriptive. The report shall be marked "In progress" under the incident analysis tab.
If an injury occurred, ensure the Company Nurse Injury Hotline (1-888-770-0925) is contacted with supervisor. Company Nurse accounts are identified as:
a. Career staff – V030
b. Volunteer – V030V
If seeking medical treatment, take FRF901 to the physician to complete. Turn in to the on-duty BC and forward to the AC. Volunteers need to turn in the form to the Chief of their department.