UHPA-PLEA Membership Application
Legal Defense enrollment form
Fill out the form below to enroll in the legal defense group.
ANNUAL GROUP RATES
| Group Rate | $105.00* |
| Supplemental Benefit | $30.00 |
| Total | $135.00 |
NOTE: ALL PRICES SHOWN ABOVE ARE ANNUAL.
*Includes $5.00 Membership Fee.
Please select a valid form