Monthly ACH Registration - Professional Educators of Iowa

Current Membership Status*

Name*

First Last

Gender*

Male
Female

Address*

Street Address Address Line 2 City State ZIP Code

Personal Email*

This will be used as your account username

Primary Phone Number*

Alternate Phone Number

Date of Birth*

Last 4 digits of SS#*

School/Employer*

School Building

School Email

Job Title*

How did you hear about PEI?

Authorization Agreement for Direct Payment Amount*

I agree to this authorization agreement.

I hereby authorize Professional Educators of Iowa to initiate debit entries to my account indicated above and to debit the same to such account, and if necessary, initiate adjustments for any transactions credited/debited in error.

I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

This authorization is to remain in full force and effect until PEI has received written notification from me of its termination no less than 15 days prior to my scheduled withdrawal date.

First payment will occur within 5 business days of form submission, and continue on a monthly basis on the same date as the first transaction.

Note: All written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in a manner specified in the authorization.

Account*

Checking Account
Savings Account

Routing Number*

(9 digit number)

Account Number*

Membership Type*

PEI Professional Membership: $24/month
PEI Supporting Membership: $10/month

Payment Date*

I agree to electronic notice.

I consent and allow PEI to send my annual renewal notice electronically.

I agree and consent that PEI may, in their sole discretion, send me communications electronically by email, text, or by making them accessible via the website or applications as permitted by law.

All Communications provided electronically under this consent will be considered to have been provided “in writing.”

By providing my consent here, I am confirming that I have access to the computer hardware and software needed to access these electronic communications.

It is my responsibility to keep my primary email address and other electronic addresses up-to-date so that PEI can communicate electronically. By consenting here, I agree that if PEI sends me an electronic communication but I do not receive it because my electronic addresses are incorrect or out-of-date, or I cannot receive electronic communications as provided under this Consent, PEI will have met any requirement to provide the communication.

You have the right to receive communications in paper form. To request a paper copy of any Communication at no charge, please write to Professional Educators of Iowa; 974 73rd Street, Suite 30, West Des Moines, IA 50265; specifying in detail the Communication you would like to receive. For the avoidance of doubt, requesting a paper copy of any communication, in and of itself, will not be treated as withdrawal of consent to receive electronic communications.

You may withdraw your consent to receive electronic renewal notices at any time, by writing to PEI. Any withdrawal of your consent will be effective after a reasonable period of time for processing your request, and PEI will confirm your withdrawal of consent and its effective date in writing (either electronically or in paper form).

If I do not wish to withdraw this Consent, but I wish to obtain a paper copy of a renewal notice that was provided electronically, I can request a paper copy from PEI.

Acknowledgement*

I acknowledge.

By submitting this application, I affirm and understand I will not receive insurance payouts or attorney representation for issues which began in whole or in part outside my effective membership dates. For applicants in need of immediate assistance with professional exposures arising from a nexus of events which began in whole or in part outside the effective membership dates please speak with a PEI representative at (515) 221-2330 to determine if you are eligible for PEI membership. Such applicants may at PEI’s sole discretion be eligible for membership but, regarding occurrences falling outside effective membership dates, are NOT eligible for insurance payouts, insurance coverage for liability incurred, or legal assistance. PEI assumes no risk for any actions or incidents which occur in whole or in part outside a member’s effective membership dates. Misrepresenting or concealing the inception date of a claim is grounds for denial of coverage and termination of membership. Additionally, I will not be eligible for any coverages regarding occurrences which are not significantly related to my professional capacity as an educational employee. Coverage by PEI will not go into effect until I receive written or electronic notice of acceptance of my application.

CAPTCHA

Monthly ACH Membership Registration

ACH Membership Payment