Tear Along Dotted Line
One Pre-Paid Way • Ada, OK 74820 • www.LegalShield.com
LegalShield is the trade name of Pre-Paid Legal Services, Inc. and its subsidiaries.
OFFICE USE ONLY
CWA PLAN
FOB FRAN
MODE GR#
Select Applicable Subsidiary: Legal Service Plans of Virginia, Inc.
Pre-Paid Legal Services, Inc. Pre-Paid Legal Services, Inc. of Florida
Pre-Paid Legal Casualty, Inc. Pre-Paid Legal Access, Inc.
Universal Member Application
LegalShield $15.95/mo IDShield Family $15.95/mo IDShield Individual $8.45/mo
LegalShield & IDShield Family $28.90/mo LegalShield & IDShield Individual $24.40/mo
MEMBER INFORMATION Please print.
Today’s Date
SSN#
Name
Mailing
Address
If you choose the bank draft option,
your account will be drafted on or
about this date each month.
For internal use only by
PPLSI. Our privacy policy is
available upon request.
X X X X X
Last _____________________________________________
First ___________________________________ MI _______
Apt./
Ste. # _____________________________________________
Street
Address _____________________________________________
City _____________________________________________
State __________ ZIP + 4 ____________________________
Member’s
Date of Birth
Spouse
Last _____________________________________________
First ___________________________________ MI _______
Work Phone
Home Phone
Email Address
_____________________________________________
I do not wish to receive email updates from PPLSI about my membership.
(Your privacy is a priority with us! PPLSI will not sell your email address or
personal information of any kind to third party vendors.)
Assigned Associate Number ________________________________________
Associate Name __________________________________________________
Associate SSN Number (If Licensed) __________________________________
Associate License Number (in Florida) ________________________________
Business Phone __________________________________________________
Signature of Associate X ___________________________________________
Associate Use Only
Applicant: I understand that the written contract sets forth the terms of my
membership, including any exclusions or limitations, and agree to be bound by the
same. I further understand that the company will mail the written contract to me
at the address noted herein within the next fourteen days. If I have not received
my contract within that time frame, I understand that it is my responsibility to call
the Pre-Paid Legal Home Offi ce at 1-800-654-7757 to obtain a copy. The written
contract, together with this application, constitutes the entire agreement between
the company and the member with respect to the membership, and there are no
agreements, understandings, warranties or representations other than as set forth
herein and in the membership contract.
In Florida, any person who knowingly and with intent to injure, defraud, or deceive
any insurer fi les a statement of claim or an application containing any materially
false, incomplete, or misleading information concerning a material fact is guilty of a
felony of the 3rd degree.
I hereby acknowledge that on this date. I purchased this plan in the city of
_____________________________ in the state of ______. By signing this application
I certify I am legally residing in the United States of America.
Signature of Applicant X________________________________________________
Dependents ____________________________________ ______/______/______
Last / First / MI Date of Birth
____________________________________ ______/______/______
Last / First / MI Date of Birth
____________________________________ ______/______/______
Last / First / MI Date of Birth
Month Day Year
Month Day Year
Ext
PAYMENT INFORMATION TO COMPLETE, select the ONE payment option you prefer. Your credit card charge or check is your receipt.
Monthly or Annual Bank Draft
Authorization for Electronic Transfers Drawn by and Payable for Premium: I hereby authorize Pre-Paid Legal
Services, Inc., to charge/draft my checking/savings account from the Financial Institution below. This authority
is to remain in eff ect until Pre-Paid Legal Services, Inc., receives written notifi cation from me revoking the
authorization. Your account will be drafted each month on or about the eff ective date of your membership.
Name of Bank _________________________________
(Financial Institution)
Bank Address _________________________________
_________________________________
CITY STATE ZIP
Acct. # _________________________________________________
Institution Transit # ______________________________________
Signature of Account Holder X _____________________________
Checking Account Savings Account
(Attach check from account to be drafted.) (Attach verifi cation.)
Please fi ll out for Bank Draft or
Credit Card payment options:
Monthly/annual draft/
charge amount
One-time enrollment fee
Total enclosed by
check, money order, or
charged to credit card
$
$
$
N/A
(If paying by credit card, I realize my fi rst charge will include
a one-time enrollment fee where applicable.)
Monthly or Annual Payment by Credit Card
I wish to pay by credit card until I revoke the authorization in writing. I realize my account will be charged on or about
the 15th or 25th monthly.
Card # Exp. Date (Mo./Yr.)
Cardholder Signature: X_____________________________________ MasterCard Visa Discover AMEX
Annual Direct Bill
I wish to pay annually by check.
Checks should be made payable
to Pre-Paid Legal Services, Inc.
Amount enclosed _____________
* Must include fi rst year payment
Important: Complete the reverse side
/www.LegalShield.com