PLEA - Beneficiary Change

CHANGE YOUR BENEFICIARY

For Your Accidental Death & Dismemberment Coverage
Current PLEA members may send us this form to add or change their beneficiary information.

* = required fields
Group Name
Note: You can find your Customer Code on your membership card. If you can not locate your Customer Code please call 1-800-367-4321 and we will be happy to assist you.
Customer Code
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth
Phone Number

Area CodePhone Number
E-mail
SSN (Last 4 Digit)
Beneficiary Name:
Beneficiary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
SIGNATURE
By typing my name above, in the Signature field, I am signing my name for you to add or change my Beneficiary on file. I understand that I am bound by all laws regarding electronic signatures.

PLEA $5,000 AD&D Disclaimer:

To be eligible for the $5,000 Accidental Death & Dismemberment coverage you must be a current member of the Professional Law Enforcement Association (PLEA) in good standing and be enrolled in a qualifying Legal Defense Plan. Should you have any questions on your eligibility, please contact our office at 1-800-367-4321.

YOU MUST PRESS THE "SUBMIT" BUTTON BELOW TO COMPLETE THE PROCESS
Should be Empty:

CHANGE YOUR BENEFICIARY