Fields marked with an asterisk are required to be filled in.
First Name *
Middle Initial
Last Name *
Date of Birth *
Social Security Number *
Retiring Agency *
Num of Years as a LEO *
Street Address *
City *
State *
Zip Code *
E-mail Address *
Alternate E-mail Address
Home Phone *
Cell Phone *
Enrollment - Step 3 Answer Questionnaire
1
Select Policy
2
Enter Profile Information
3
Answer Questionnaire
4
Enter Payment Information
All questions are required to be completed.
1. Did you carry prior Professional Liability Insurance during your Federal career?
2. Have you ever had your authority to carry a firearm suspended, revoked, or otherwise restricted?
3. In the last 5 years, have you had any claims or LEOSA occurrences that could result in a claim?
4. Do you familiarize yourself with state gun laws (including home state) prior to carrying weapon in that state?
5. Do you have any prior LEOSA coverage?
6. Have you ever been convicted of a crime?
7. Are you a qualified retired law enforcement officer as defined by the Law Enforcement Officers Safety Act (LEOSA) of 2004 and all of its amendments, codified as Title 18 U.S.C. & 926 c, including the National Defense Authorization Act (NDAA) for fiscal year 2013?
Photographic Identification issued by the former agency must be carried at all times in which a firearm is being carried.
Enrollment - Step 4 Enter Payment Information
1
Select Policy
2
Enter Profile Information
3
Answer Questionnaire
4
Enter Payment Information
Premium
$ 0.00
Admin fee
$ 0.00
Tax
$ 0.00
Add'l State Surplus Lines Tax
$ 0.00
State Stamping Fee
$ 0.00
State Transaction Fee
$ 0.00
4% Credit Card fee
$ 0.00
Total due
$ 0.00
Note: Credit card transactions incur an additional 4% fee.
Credit Card Number
Expiration Month / Year/
CCV
Enable AutoPay?
Use the same Credit Card
Use the following bank account
Bank Routing Number
Bank Account Number
ACH Checking Account Debit Authorization
Premium payments will be debited from your checking account on the 1st day of the month when the payment
is due (or next business day if weekend or holiday). Any ACH’s payments that are declined/returned will
incur a service charge fee of $35 (you will be notified via mail and email to make other payment arrangements).
You will still receive a renewal notice in via US Postal Service, however, it will be marked “Do Not Pay –
ACH Scheduled”. Any changes to your banking information that you provide below must be submitted in writing 30
days prior to the next scheduled payment. The ACH Debit service will stay in force until revoked by the member
in writing. By signing below, you agree to the terms and conditions set forth and authorize Mass Benefits
Consultants/CareerGuard to debit your checking account as described below when premium payments are due. A
confirmation will be sent to you with the schedule of your recurring payments.
Bank Routing Number
Bank Account Number
Enable AutoPay?
ACH Checking Account Debit Authorization
Premium payments will be debited from your checking account on the 1st day of the month when the payment
is due (or next business day if weekend or holiday). Any ACH’s payments that are declined/returned will
incur a service charge fee of $35 (you will be notified via mail and email to make other payment arrangements).
You will still receive a renewal notice in via US Postal Service, however, it will be marked “Do Not Pay –
ACH Scheduled”. Any changes to your banking information that you provide below must be submitted in writing 30
days prior to the next scheduled payment. The ACH Debit service will stay in force until revoked by the member
in writing. By signing below, you agree to the terms and conditions set forth and authorize Mass Benefits
Consultants/CareerGuard to debit your checking account as described below when premium payments are due. A
confirmation will be sent to you with the schedule of your recurring payments.
Enrolling via Bi-Weekly Payroll payments, there are times when a payroll
payment is missed due to LWOP, extended medical leave, military, suspension,
etc. By providing your banking information this insures you will not have
any gap in coverage should a payroll payment be missed. You will be
notified via email & regular USPS mail should a draft payment take
place. Your banking information is securely stored and protected. Your
continued submission of the Bi-Weekly enrollment acknowledges and authorizes
CareerGuard to draft premium payments in the event of missed allotments.
Bank Routing Number
Bank Account Number
Terms and Conditions
I hereby apply for coverage under CareerGuard® for which I am eligible as an
employee of the Federal Government in good standing. It is understood that
any act, error or omission, allegation or knowledge thereof that occurs
prior to the effective date and/or retroactive date of coverage will not
be covered by the policy. Policy is issued on an annual basis and is
payable for the complete annual policy. No refund of premium except
for retirement/resignation. I have read above fraud statement for my
state if applicable. Policy is not bound or in force until you are
issued policy documentation.
I agree to the Terms & Conditions set forth above.
I hereby apply for coverage under CareerGuard® for which I am eligible as an
employee of the Federal Government in good standing. It is understood that
any act, error or omission, allegation or knowledge thereof that occurs prior
to the effective date and/or retroactive date of coverage will not be covered
by the policy. Policy is issued on an annual basis and is payable for the
complete annual policy. No refund of premium except for retirement/resignation. I
have read above fraud statement for my state if applicable. Policy is not
bound or in force until you are issued policy documentation.
I agree to the Terms & Conditions set forth above.
I hereby apply for coverage under CareerGuard® for which I am eligible as an
employee of the Federal Government in good standing. It is understood that any
act, error or omission, allegation or knowledge thereof that occurs prior to
the effective date and/or retroactive date of coverage will not be covered by
the policy. Premium is 100% earned and policy is issued on an Annual basis
regardless of payment cycle. No refund of premium except for retirement/resignation.
Policy is not bound or in force until you are issued policy documentation. It
is also agreed premium payments will be debited from my bank as listed above on
the payment cycle chosen. I acknowledge a service charge of $35 will be incurred
for any returned payment. This AutoPay will stay in force until withdrawn in
writing by me. I have read above fraud statement for my state if applicable.
I agree to the Terms & Conditions set forth above.
Fraud Notice
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO ALABAMA APPLICANTS AND CLAIMANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines, or confinement in prison, or any combination thereof.
NOTICE TO ALASKA CLAIMANTS: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
NOTICE TO ARIZONA CLAIMANTS: For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA APPLICANTS AND CLAIMANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO CALIFORNIA CLAIMANTS: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE TO COLORADO APPLICANTS, POLICYHOLDERS AND CLAIMANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DELAWARE CLAIMANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS AND CLAIMANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO APPLICANTS OF FLORIDA AND CLAIMANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
NOTICE TO IDAHO CLAIMANTS: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
NOTICE TO INDIANA CLAIMANTS: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
NOTICE TO APPLICANTS OF KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
NOTICE TO MAINE APPLICANTS AND CLAIMANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Signature
Use your mouse or touchscreen (if applicable). Then click Save Signature before Submitting.
Enrollment - Processing payment and submitting enrollment
Processing . . .
Payment successful
Please allow 5 business days for processing then your policy documents will be
emailed to you. Thank you for joining CareerGuard.
Enrollment successful
Please allow 5 business days for processing then your policy documents will be
emailed to you. Thank you for joining CareerGuard.
Payment failed. Please click Previous to recheck entries and try again.
Enrollment - Payroll Setup
1
Select Billing Cycle
2
Enter Profile Information
3
Enter Prior PLI / Beneficiary Information
4
Enter Payment Information
Thank you for joining CareerGuard® Professional Liability Insurance Plan. Your
enrollment form has been received and you have elected to pay your premiums through
payroll deduction. Your coverage will be effective on the day your enrollment
form was received, provided we receive your first allotment payment during that same
pay period of your effective date.
You must start your payroll allotment through Employee Express, EPP, or My Pay, as
we cannot start the allotment for you. Our banking information you will need to
start the deduction is as follows:
Routing #056004445
Account #70033307
Account Type is Checking
If you do not have online access to your Earnings & Leave (click here to download
the Direct Deposit Sign-up Form), you must complete the Direct Deposit Form
attached and submit it to your payroll office. Also, please monitor your pay stubs
to be sure the deduction has started.
If you have any questions, please feel free to call 1-800-221-3083.
Next Steps
