CRIMINAL AND CIVIL PROTECTION for only $91.88* (Annually)

 * = Includes annual non-refundable $5.00 Membership Fee

First Name:    Last Name:

Phone #:
Address:

City: State:   Zip:

Social Security #: (Last 4 digits):        Date of Birth:

E-Mail 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 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:

If you chose to add the Civil Coverage and you would like the free Accidental Death & Dismemberment Coverage then you must complete the form below.
If you did not choose the Civil Coverage Option then please skip to the payment section below.

I would like the Civil Coverage but I would like to opt out of the free $5,000 Accidental Death & Dismemberment Coverage.  I have indicated this option by checking this box and therefore I may skip filling out the Beneficiary information below and proceed to the payment section.

Beneficiary Name:

Beneficiary Address:

Beneficiary City: Beneficiary State: Beneficiary Zip:

Relationship:

Signature:   Date:

We accept the following ways to pay: Visa, MasterCard or Discover.

Credit Card Information:

Credit Card:  Visa   MasterCard   Discover
Name On Card: 

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

I would like this to be a:  One Time Payment Recurring Payment

Signature: 
By typing my name above, in the Signature field, I am signing my name for you to charge my credit card the amount shown above.  I am bound by all laws regarding electronic signatures.

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

Note: you can charge up to 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 the Company 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 the Company received actual payment at its home office.  This payment shall in no way alter or amend the provisions of the policy and no one other than the policyholder and his assignees will have any interest in the policy. This payment plan shall continue in effect until terminated by the Company or by me.  In addition the Company may terminate this payment plan immediately if any charge is dishonored upon presentation.

 YOU MUST PRESS THE "SUBMIT" BUTTON BELOW TO COMPLETE YOUR PAYMENT.