Clergy

Enrollment

Enrollment in our programs is a very simple process. If you are ordained as a Deacon, Priest or Bishop in The Episcopal Church and live or are canonically resident in Pennsylvania, or if you are a Lutheran or Moravian Pastor serving an Episcopal congregation or diocese in Pennsylvania, simply complete this form and submit it to us.

Application for Enrollment

Title *

First Name *

Last Name *

Current Status *

Date of Birth *

Place of Birth *

Age at Nearest Birthday *

Place of Employment *

City

Canonical Residence/License *

Preferred Mailing Address *

City *

State *

Zip Code *

Primary Phone *

Alternate Phone

Email Address

Amount of Insurance Requested: Free $1,000 Introductory Policy

I hereby declare that the answers above on this Application are complete and true and correctly recorded to the best of my knowledge and belief. I agree that the declarations and statements on this application shall be the basis of the contract between the said Corporation and myself; and that this Application and any Policy that may be issued shall be subject to defeasance and all the provisions stated or contained in the By-Laws of the Corporation.