PLEA-Team Legal

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Please provide the following information to continue processing of our Application:

Name of Employer:

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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 the plan:

By typing my name below, in the Signature field, I am signing my name to enroll in the PLEA Legal Defense Fund and Participation in the PLEA Legal Defense Plan. I am bound by all laws regarding an electronic signature.

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AD&D Opt Out

NOTE: If this information below is NOT completed you will NOT receive this free benefit.

NO REFUNDS

You must complete the following information below to receive the free $5,000 AD&D coverage:

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Relationship:

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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.

Payment

Annual Civil & Criminal$116.00

Telephone Consultation Program$48.00

Pre-Paid Legal Program$120.00

HR 218 Add-on Option$60.00

H.R. 218
Item subtotal:

Accidental Death & Dismemberment Member Only$24.00

AD&D Member Only

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Total $0.00

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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.

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

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PAYMENT INFORMATION:

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