PLEA - Online Payment

Account #
Ex. MCMALEP - This is found on the upper right hand of your bill.
Full Name

First NameMiddle NameLast NameSuffix
Current Billing Address on Invoice

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail

PAYMENT INFORMATION:

Payment

USDAmount

Credit Card Information

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address of Credit Card

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

SIGNATURE
By typing my name above, in the Signature field, I am signing my name for you to charge my credit card the amount shown above. I am bound by all laws regarding electronic signatures.

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

Note: You can charge up to the amount shown on the Enrollment Form. If you choose a recurring payment, the amount will be charged on a regular basis on or about the due date. It is not necessary for PLEA 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 PLEA 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 member and his assignees will have any interest in the plan. This payment plan shall continue in effect until terminated by PLEA or by me. In addition, PLEA may terminate this payment plan immediately if any charge is dishonored upon presentation.

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

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
Should be Empty: