PLEA INDIVIDUAL LEGAL DEFENSE ENROLLMENT FORM
Social Security (Last 4 digits)____________________Date of Birth:______________
Name of Employer:____________________________________________
Years with Current Employer:_______________________________________
I hereby apply for enrollment in the PLEA Legal Defense Fund. 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.
Complete, sign and mail your completed application to: PLEA PO BOX 1197, Troy, MI 48099. Should you have any questions, please call Toll Free 800-367-4321.
Legal Defense coverage includes the following at NO additional cost to you:
$5000.00 of Accidental Death and Dismemberment coverage.