Communications Member Application - Colorado State Patrol Association

Personal Info

First Name

Last Name

Personal Mobile Phone

Personal Email

Choose a password

State email addresses are not acceptable.

You must use a personal email address for your account. The association is a separate entity from the State Patrol. We cannot accept @state email addresses. Please enter a personal email address.

Date of Birth

Last 4 of SSN

Address Line 1

Address Line 2

City

State

Zip Code

CSP Employment Info

Are you a spouse of a current member of the association?

Yes

No

Your spouse's full name

Hire Date

Years with the Colorado State Patrol?

IBM Number

Assigned Duty Station

PLEA Group Legal Defense is the legal defense for association members. As a member, this valuable policy provides you with 24-hour coverage for both duty-related civil, criminal, and administrative actions. “Plan A” of the HR-218 legal defense coverage, and an additional $5,000 of Accidental Death & Dismemberment (AD&D) coverage are included in the plan. This optional benefit is $13.75 per month, and is a small price to pay for peace of mind protection. The benefit is available to both sworn and civilian members.

24 Hours a Day – 7 Days a Week – 365 Days a Year

Legal Defense Coverage

Do you want PLEA coverage?

Yes, I want coverage ($13.75/month)

No, I accept personal financial responsibility for my own legal defense.

Are you sure?

I acknowledge that in refusing PLEA coverage I am responsible for my own legal defense while a member of the association.

Eligibility

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 benefit is in effect until this Enrollment Form 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 benefit under the Plan:

Current Litigation (if any)

Signature

Please sign here

Insurance Coverage

At NO additional cost to you, your legal defense plan includes a $5,000 AD&D (Accidental Death & Dismemberment) wage recovery benefit. It is valid 24 hours (on or off duty). Please identify your beneficiary for this benefit below.

Beneficiary Name

Relationship

Almost Done...

To complete your membership process, press the "Join Now!" button below. You will be redirected to the secure checkout page where you'll enter your payment information and complete your membership.

Your monthly recurring dues with PLEA coverage included will start at
$33.75 and will increase to the standard rate of $42.75 after the first year.

Your monthly recurring dues with PLEA coverage included will be
$33.75

Your monthly recurring dues will start at $20 and will increase to the standard rate of $29 after the first year.

Your monthly recurring dues will be
$20