YOUR INFORMATION

Pre-Paid Legal Application

*You must be a member in good standing of the Legal Defense Plan to add this coverage*
Customer Code:*
Ex. MCMALEP
Full Name*

First NameLast Name
Email*
example@example.com
Last Four Digits of SSN*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PAYMENT INFORMATION

Payment*

Pre-Paid Legal Coverage$120.00

Enter coupon

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Electronic Signature*
By signing above, I agree to the following terms: I agree for The Professional Law Enforcement Association to charge my American Express, Discover, MasterCard or Visa to make my entire payment.

Note: You can charge up to the amount shown on the Enrollment Form. The amount will be charged on a regular basis on or about the due date. It is not necessary for the Company to notify me when this is done. Any requirement for giving notice due shall be waived as long as this payment plan is in effect.. No payment or portion thereof shall be deemed to have been paid unless and until the Company received actual payment at its home office. This payment shall in no way alter or amend the provisions of the plan and no one other than the participant and his assignees will have any interest in the plan. This payment plan shall continue in effect until terminated by the Company or by me. In addition the Company may terminate this payment plan immediately if any charge is dishonored upon presentation.

Please note that effective January 1, 2023 our addresses have changed:

Physical Address: 850 W. University Drive, Suite A, Rochester, MI 48307

Mailing Address: P.O. Box 82263, Rochester, MI 48308-2263
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