Attn: Colorado & Texas Law Enforcement.  Contact Leslie McMahon at 1-800-367-4321, ext. 1010  before filling out this form for special conditions.

 Individual Annual Fee: $130.00 plus $1.00 Membership = $131.00 (Not including Supplemental Protection)
      
 CHOOSE ONE - Preferred Payment

Annual payments (No service Fee).
Quarterly payments (add $3 service fee to total amount).
Semi-annual payments (add $3 service fee to total amount).


Optional - add the Supplemental Benefit  my credit card charge will be $161.00 per year (this includes the Individual and Supplemental Legal Defense Protection).

* - REQUIRED FIELDS!

*Name:        *Phone #: (xxx-xxx-xxxx)

Note:  you must provide us with your billing address below.

*Address:
*City:       *State: *Zip:
*Group Affiliation:       (Type "Individual" if not applicable)
*Social Security#:         (last 4 digits only)
*Email Address: 

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 PLEA.  To my knowledge, I am not presently named in any suits, action or proceeding nor under investigation for a duty-related incident, except for the following:


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 a  electronic signature.

*Signature:
 

PAYMENT:

We accept the following payments: Visa or MasterCard!

* = required information

* Credit Card:  Visa   MasterCard
* Name On Card: 

Credit Card Billing Address
* (if different from Applicant's Address above):

* Card Number:    
* Expiration Date:      /    

* CVV2# :            what is this?
* Signature: 

Note: Your Credit Card Will be billed Automatically until you cancel.

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

Note: Your coverage is not in effect until your credit card is approved.

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

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

If you experience any problems with this form please call us at 1-800-367-4321 Ext.1003.