Individual Legal Defense

If you are a member of a group please use the Group Coverage sign up page with your Group Discount Code.

To pay by Check or money order (click here)

To pay by Visa, MasterCard, Discover or American Express fill in the form below and hit the "Submit" button.
* - REQUIRED FIELDS

Full Name

First NameMiddle NameLast Name

Phone Number Home

Area CodePhone Number

Phone Number Cell

Area CodePhone Number

Phone Number Work

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Group Affiliation: (Type "Individual" if not applicable)

SSN (Last 4 Digit)

Your Birth Date

MonthDayYear

E-mail

How did you hear about PLEA?

Other Please Explain

Name of Employer:

Position:

Years With Current Employer:

Other Professional Affiliations:

I hereby apply for enrollment in the PLEA Legal Defense Fund and Participation in the PLEA Trust. I agree to abide by all terms and conditions thereof. I understand that no coverage is in effect until this application is approved by the Plan Administrator. To my knowledge, I am not presently named in any suits, actions, or proceedings, nor under investigation for a duty-related incident, except the following, for which there would be no coverage:

By typing my name below, in the Signature field, I am signing my name to enroll in the PLEA Legal Defense Fund and Participation in the PLEA Legal Defense Plan. I am bound by all laws regarding a electronic signature.

SIGNATURE

AD&D Opt Out

NOTE: If this information below is NOT completed you will NOT receive this free benefit.

You mustcomplete the following information below to receive the free $5,000 AD&D coverage:

Beneficiary Name:

Relationship:

Please Select

Annual Legal Defense Coverage - Civil, Criminal & Administrative, Unlimited Supplemental Administrative$262.00

Telephone Consultation Program$48.00

Pre-Paid Legal$120.00

H.R. 218 - Add-on Option$60.00

H.R. 218

Accidental Death & Dismemberment Member Only$24.00

AD&D Member Only

Total $0.00

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

CARD MEMBER ACKNOWLEDGES RECEIPT OF SERVICES AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CARD MEMBER'S AGREEMENT WITH THE ISSUER.

YOU MUST COMPLETE THE FORM AND PRESS THE "SUBMIT" BUTTON TO COMPLETE YOUR ENROLLMENT!

NO REFUNDS

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

CHOICE OF COUNSEL

The Participant has the free and unrestricted right to employ an attorney of his or her choice. The Plan has no obligation to recommend counsel and is not a guarantor in any manner of the skill of counsel chosen by participant, even if the attorney is a Participating Attorney.

The Plan does not guaranty the availability of a Participating Attorney in the Participant’s geographical area. This may result in the Participant’s need to hire a Non-Participating Attorney at added expense to the Participant. The Plan is not obligated to pay for the costs of a Non-Participating Attorney except as set forth in the Schedules of Benefits in the Plan Description.

Important: Once Enrollment Form has been approved by the Plan Administrator coverage begins the first or the fifteenth of the month following receipt of the completed enrollment and payment in our office.

Because we rely on outside vendors for our Membership Cards and Welcome Packets please allow 4-6 Weeks to receive your Welcome Packet.

NO REFUNDS

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PAYMENT INFORMATION:

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