PLEA - HR 218

Status

Full Name

First NameMiddle NameLast Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SSN (Last 4 Digit)

E-mail

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Other Please Explain

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:

Credit Card

My Plan

Plan A - $5,000 Criminal & $10,000 Civil$61.00

Plan B - $10,000 Criminal & $20,000 Civil$121.00

Plan C - $15,000 Criminal & $30,000 Civil$181.00

Plan D - $20,000 Criminal & $40,000 Civil$241.00

Plan E - $25,000 Criminal & $50,000 Civil$301.00

Plan F - $30,000 Criminal & $60,000 Civil$361.00

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 checked 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 ENROLLMENT!

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.

NO REFUNDS

If you experience any problems with this form please call us at 1-800-367-4321

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

PAYMENT INFORMATION:

My Plan