List of Firefighters for Income Protection PlanMunicipal League Worker’s Compensation Trust 501-978-6127

To join or renew the League’s Firefighters Income Protection Plan for volunteer and part-paid firefighters of your city or town please provide the following:

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Submit this completed list with the names of your volunteer and part-paid firefighters with check payable to:Firefighters Income Protection Plan P.O. Box 37 North Little Rock, AR 72115

Number of Firefighters X $20.00 = City/Town Name: Date: Completed by:

(Your Name)

(Your Title) (Your Phone)