PLEA - Claim Reporting Form

SUBMIT A CLAIM

Please Complete this form before calling the PLEA Claims Department to report a claim.
Member’s Full Name

First NameMiddle NameLast Name
Client Code / Account Number
Example: MCMABRP
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #

Area CodePhone Number
Cell Phone/Other

Area CodePhone Number
SSN (Last 4 Digit) and/or Badge #
E-mail
(example@example.com) We recommend personal Email
Law enforcement employer and employers address

Employer

Street Address

CityState / Province

Postal / Zip CodeCountry
Date of incident resulting in (or which may result in) discipline or lawsuit?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Specifically describe the incident leading up to the claim presented for review
Specifically describe any charges or discipline:
Has a Lawsuit been filed against you?
If so, County of filing:
Have you contacted an attorney? If so, provide name, complete address, and telephone number
Attorney Name

First NameMiddle NameLast Name
Attorney Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Signature
Please scan and attach any documentation that you may have from your employer to support your claim.

Browse Files
PDF documents are preferred. Cancelof
A Claim Representative will contact you to discuss your claim.
Should be Empty:

SUBMIT A CLAIM