CHECK ONE - Annual Fee

Group (per member) $100.00 plus $1.00 Membership = $101.00 + $30.00 Optional Supplemental.                     (75% minimum participation)

Group (per member) $130.00 plus $1.00 Membership = $131.00 + $30.00 Optional Supplemental                      (25% minimum participation)
 

CHECK ONE - Preferred Payment
Quarterly payments (add $3 service fee to total amount, per payment).
Semi-annual payments (add $3 service fee to total amount, per payment).
Annual payments (No service fee).

Name of Organization:

Note: Please enter the billing address below.
Address:
City: State: Zip:
Contact Person:    
Telephone:   Fax:
Email Address:   

Coverage                                  
Civil                                      
Criminal                                
Administrative                       
Supplemental                        

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

We understand that upon acceptance by the P.L.E.A. Trust, participation will begin on the first month following receipt of the this Authorization Form, and appropriate fee, we will receive a confirmation letter indicating our effective date.
 

NUMBER OF ELIGIBLE MEMBERS
NUMBER OF MEMBERS ENROLLED

PARTICIPATION    100%     25% OR MORE        LESS THAN 75%     
 SIGNATURE ORGANIZATION: 

By typing my signature above I am signing my name for you to enroll me in the PLEA Legal Defense Fund and Participation in the PLEA Supplemental Benefit.  I am are bound by all laws regarding electronic signatures.

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

 
PAYMENT:

We accept the following payments: Visa, MasterCard.

Credit Card Information:
 Credit Card:  Visa   MasterCard
Name On Card: 

Card Number:    
Expiration Date:            /      
                               Month      Year
CVV2# :       what is this?
Signature: 

 Your credit card will be re-billed annually unless you cancel or you have chosen the quarterly or Semi-Annually option at the top of this form. 
 

CARDMEMBER ACKNOWLEDGES RECEIPT OF SERVICES AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CARDMEMBER'S AGREEMENT WITH THE ISSUER.
 

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