Universal Member Application: Personal Information

PRE-PAID LEGAL SERVICES, INC.
, AND SUBSIDIARIES
UNIVERSAL MEMBER APPLICATION

Subsidiaries list Pre-Paid Legal Services, Inc. Pre-Paid Legal Casualty, Inc. Pre-Paid Legal Services, Inc. of Florida Legal Service Plans of Virginia, Inc.
AA.PPL.05.07
Corporate Offices: One Pre-Paid Way Ada, OK 74820 www.prepaidlegal.com
CHECK ONE:
Standard Plan Expanded Plan Commercial Drivers Legal Plan ($25 Enrollment Fee) Law Officers Legal Plan Exp. Law Officers Legal Plan * Some plans may not be available in certain states.
Home-Based Business Plan Legal Shield IDT IDT GOLD LPSE Other*__________________
OFFICE USE ONLY CWA FOB MODE PLAN FRAN GR#
personal information
Applicants SSN
For internal use only by PPLSI. Our privacy policy is available upon request.
Todays Date If you choose the bank draft option, your account will be drafted on or about the above date each month.
MAS
Please print in ALL CAPITAL letters. Use ONLY BLUE or BLACK INK. FAILURE TO PRINT LEGIBLY can cause DELAYS IN PROCESSING YOUR APPLICATION.
The information you provide on this application is considered non-public information, and Pre-Paid Legal takes care to protect your information.
DOB Mr. Mrs. Miss. Ms. Dr. A $10 non-refundable fee is required for individual enrollments.
Applicants Last Name (First Name) * Spouses Last Name (First Name) Apt. # / Ste # Mailing Address City State ZIP + 4 Business Phone Email Address Cell # Ext. Middle Initial
CONFIDENTIAL
(*Spouse includes Domestic Partners, Civil Union Partners, Same-Sex Partners, or other term specifically defined by any local, state or federal statute.)
Middle Initial
(COMPLETE ADDRESS, NO ABBREVIATIONS PLEASE)
( (
) )
Home Phone
(Your privacy is a priority with us! PPLSI will not sell your email address or personal information of any kind to third party vendors.)
associates only
Assigned Associate Number Associate Last Name First Name Associate SSN Number (If Licensed) Business Phone Associate Lic. Number (In Florida) Middle Initial
( X
Ext.
Signature of Associate
APP.UNI (1.10)
dependent information
Last Name, First Last Name, First Last Name, First Last Name, First Last Name, First Last Name, First Last Name, First Middle Initial Middle Initial Middle Initial Middle Initial Middle Initial Middle Initial Middle Initial DOB DOB DOB DOB DOB DOB DOB
payment information
Monthly or
Name of Bank
To ComPleTe, Fill out the oNe payment option you prefer. Your credit card charge or check is your receipt.
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 listed below. This authority is to remain in effect until Pre-Paid Legal Services, Inc., receives written notification from me revoking the authorization. Your account will be drafted each month on or about the effective date of your membership.
Annual Bank Draft
Address City State Account # Transit # Checking Account

(Attach check from account to be drafted.)
ZIP + 4
CONFIDENTIAL
Savings Account
(Attach verification.)
Signature of Account Holder
When you provide Pre-Paid Legal Services, Inc. with a check presented as payment, you authorize Pre-Paid Legal Services, Inc. to use the information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. Funds may be withdrawn from your account as soon as the same day payment is received. For inquiries please call: 800-654-7757.
I wish to pay by credit card until I revoke this authorization in writing. I realize my account will be charged each month (or Annually) on or about the effective date of my membership.
Cardholders Last Name First Name Card # Exp. Date Cardholders Signature MasterCard Discover Visa American Express Middle Initial
Monthly or
Annual Payment by Credit Card
Please fill out for Bank Draft or Credit Card

payment options:
Monthly /Annual draft/ Charge amount
$ $ $ $
X
Semi-Annual Direct Bill
One-time enrollment fee First Payment/ Draft Total Total enclosed by check, money order, or charged to credit card
. . . .
I wish to pay Annually/Semi-Annually by check. Checks should be made payable to Pre-Paid Legal Services, Inc. Amount enclosed
Annual Direct Bill or
*Must include first payment and enrollment fee.
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 Office 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 files 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. In NJ, any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. In TN, it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. 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.
Applicant: I understand that the written contract sets forth the terms of my membership, including any exclusions or limitations,
(If paying by credit card, I realize my first charge will include a one-time enrollment fee where applicable.)
Signature of Applicant

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PRE-PAID LEGAL SERVICES, INC.

UNIVERSAL MEMBER APPLICATION

Corporate Offices: One Pre-Paid Way Ada, OK 74820 www.prepaidlegal.com

OFFICE USE ONLY CWA FOB MODE PLAN FRAN GR#

(COMPLETE ADDRESS, NO ABBREVIATIONS PLEASE)

Annual Bank Draft

Address City State Account # Transit # Checking Account

Signature of Account Holder

Annual Payment by Credit Card

Please fill out for Bank Draft or Credit Card

Annual Direct Bill or

*Must include first payment and enrollment fee.

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