TL Group Enrollment Form

^ = Required information by the Insurance Company in order to receive the $5,000 Accidental Death & Dismemberment coverage.

Group Code

Example I-LAKES

Full Name

First NameMiddle NameLast Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

SSN (Last 4 Digits)

Date of Birth

MonthDayYear

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

Payment

Civil & Criminal $90.88

Telephone Consultation Program$39.00

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

H.R. 218
Item subtotal:

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^

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. By pressing the Submit button you are E-Signing your Signature and that all informaion is correct.

YOU MUST COMPLETE THE FORM AND PRESS THE "SUBMIT" BUTTON TO COMPLETE YOUR ENROLLMENT!

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

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.

* Includes $10.00 Membership Fee.

Payment Information

Payment