TL Group Authorizattion

How did you hear about us?

Name of Organization

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Name

First NameMiddle NameLast Name

Phone

Email

Fax

Coverage Inception

Billing

Coverage

Civil & Criminal Total = $7.15 x # of Members x Number of months

Membership Fee Per Year = $5.00 x # of Members

Grand Total = Civil & Criminal Total + Membership Fee Per Year

We hereby apply for enrollment in the Professional Law Enforcement Association, and request participation in the PLEA Legal Defense Fund Trust.

We understand that upon acceptance by the PLEA Trust, participation will begin on the first day of the month following receipt of the Authorization Form. We will receive a confirmation invoice indicating the effective date

Who is responsible for invoices?

Number of eligible members

Number of members enrolled

Claims Experience

Participation

The undersigned represents that he/she is authorized by each member of the above named group to make application on their individual behalf for membership in PLEA and participation in the PLEA Legal Defense Fund and agrees to be responsible for and assume the fiduciary duty to distribute to each member of the group, identification cards, plan booklets/Summary Plan Descriptions, Notices of Material Modifications, any annual notices and any communications from PLEA or the PLEA Legal Defense Fund, personally, to each member upon request of PLEA or upon request of any member and will hold PLEA, its officers and employees, and the Trustees of PLEA Legal Defense Fund harmless against any claim arising out of his/her failure to do so

Signature - Organization

Important : Protection begins the first of the month following receipt of payment and application approval.

GENERAL INFORMATION

COVERAGE INFORMATION