PLEA - LD Group Enrollment Form

Full Name

First NameMiddle NameLast Name

Group Name

Please enter Group Discount Code below in payment section.

Phone Number Home

Area CodePhone Number

Phone Number Cell

Area CodePhone Number

Phone Number Work

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SSN (Last 4 Digits)

Birth Date

MonthDayYear

E-mail

Email Subscription

Name of Employer

Position

Years with current employer

Other Professional Affiliations

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 under Plan:

I have read, understand and agree to the terms and conditions of the Legal Defense Summary Plan Description

Signature

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Annual Legal Defense Coverage - Civil, Criminal & Administrative, Unlimited Supplemental Administrative$262.00

Telephone Consultation Program$48.00

Pre-Paid Legal$120.00

H.R. 218 - Add - On Option$60.00

H.R. 218

Accidental Death & Dismemberment Member Only$24.00

AD&D Member Only

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Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Legal Defense coverage includes the following at NO additional cost to you:

✓ HR 218 - Plan A.

✓ $5,000 Accidental Death & Dismemberment (AD&D), 24 hour, on and off duty

Beneficiary Name

Relationship

Signature

CHOICE OF COUNSEL

The Participant has the free and unrestricted right to employ an attorney of his or her choice. The Plan has no obligation to recommend counsel and is not a guarantor in any manner of the skill of counsel chosen by participant, even if the attorney is a Participating Attorney. The Plan does not guaranty the availability of a Participating Attorney in the Participant’s geographical area. This may result in the Participant’s need to hire a Non-Participating Attorney at added expense to the Participant. The Plan is not obligated to pay for the costs of a Non-Participating Attorney except as set forth in the Schedules of Benefits in the Plan Description 07/11 PLEA Group Legal Defense Enrollment Form

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.

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

NO REFUNDS

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

GENERAL INFORMATION

PAYMENT INFORMATION

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GENERAL INFORMATION

PAYMENT INFORMATION

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