IS U3S3.w- o Pre-Paid LegalServices,Inc.,and subsidiaries ... · Inc.,tocharge/draft...
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11111111111111111111111111 IS U3S3.w- 0 Pre-Paid Legal Services", Inc. o Pre-Paid Legal Casualtyl", Ine. o Pre-Paid Legal Services of Tennessee, Inc. o Pre-Paid Legal Services, Inc. of Florida o National Pre-Paid Legal Services of Mississippi, Inc. o Legal Service Plans of Virginia, Inc. o Ohio Access to Justice, Inc. administered by Pre-Paid Legal Seroices", Inc. OFFICE USE ONLY CWA FOB MODE PLA.N FRAN GR# Pre-Paid Legal Services", Inc., and subsidiaries Corporate Offices: P.O. Box 145· Ada, OK 74821-0145 UNIVERSAL • nieiribershi p application 'YIiHt·i!ii:t.5,·jUt M 0 Standard Plan 0 Expanded Plan o Commercial Drivers Legal Plan ($25Enrollment Fee) o Law Officers Legal Plan 0 Exp. Law Officers Legal Plan o Home-Based Business Plan (1st time enrollee) o HBB Rider only (must be same payment method as Expanded Plan) o Legal Shield 0 Other' _ 'Some plans may not be available in certain states. A $10 non-refundable fee is required for individual enrollments. IRO member information Please print. ~ /~ /~ If you choose the bank draft option, U-.-J U-.-J ~ your account will be drafted 011 or Month Day Year about this date each month. ~ ~ ~ Forinternaluseonlyby ~ - U-.-J - ~ PPLSI.Ourpnvacypollcy is available upon request. AssignedAssociateNumber _ AssociateName _ AssociateSSN Number(lfLicensed) _ Associate License Number(ln Florida) _ _ BusinessPhone _ Signature of Associate X Today's Date SSN# Name Last 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 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 Rorida, 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. First Mailing Apt./ Address Ste.# Street Address _ City State ZIP + 4 Member's OJ/OJ/~ Date of Birth ~ Month Day Year Spouse Last 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. MI First UTI-UTI-LlllJ Ext. ITIIJ UTI-UTI-LlllJ Work Phone Signature of Applicant.=.X-"-- _ Home Phone / / Dependents Last / First / MI Dateof Birth / / EmailAddress Last / First / MI Dateof Birth / / CJ I do 110twish to receive email updates from PPLSI about my membership. (Your privacy is a priority with us! PPLSI uiill not sell your email address or personal information of any kind to third party vendors.) Last / First / MI DateofBirth p aym en t info rma tion TO COMPLETE, selecUhe ONE payment option you prefer. Your credit card charge or check is yourreceipt. o 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 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. Please fill out for Bank Draft or Credit Card payment options: $DIIIJ $[0]] Monthly/Annualdraft/ Charge amount One-time enrollment fee Acct. # _ Institution Transit # ----------------------------- Signature of Account Holder=-X=--- _ o Checking Account 0 Savings Account (Attach check from account to be drafted.) (Attach verification.) Name of Bank _ (FinancialInstitution) Bank Address _ Totalenclosedby check, moneyonler, orchargedtocreditcanl $DIIIJ (If paying by credit card, I realize my first charge will include a one-time enrollment fee where applicable.) CITY ZIP STATE o Monthly or Annual Payment by Credit Card Iwish to pay by credit card until I revoke this authorization in writing. I realize my account will be charged on or about the 15th or 25th monthly. Exp. Date: [UJJ (Mo.jYr.) [J Annual Direct Bill Iwish to pay annually by check. Checks should be made payable to Pre-Paid Legal Services,lnc. Card #: Amountenclosed: _ o MasterCard 0 Visa 0 Discover 0 AMEX *Mustincludefirstyearpayment. Cardholder' Signature: X ~-------------------------- APP.UNI (7.02).50994 ©2002 Pre-PaidLegalServices",lnc.,Ada,OK
Transcript of IS U3S3.w- o Pre-Paid LegalServices,Inc.,and subsidiaries ... · Inc.,tocharge/draft...
11111111111111111111111111IS U3S3.w- 0 Pre-Paid Legal Services", Inc.
o Pre-Paid Legal Casualtyl", Ine.o Pre-Paid Legal Services of Tennessee, Inc.o Pre-Paid Legal Services, Inc. of Florida
o National Pre-Paid Legal Services of Mississippi, Inc.o Legal Service Plans of Virginia, Inc.
o Ohio Access to Justice, Inc.administered by Pre-Paid Legal Seroices", Inc.
OFFICE USE ONLY
CWA
FOB
MODE
PLA.N
FRAN
GR#
Pre-Paid Legal Services", Inc., and subsidiariesCorporate Offices: P.O. Box 145· Ada, OK 74821-0145
UNIVERSAL •nieiribershi papplication 'YIiHt·i!ii:t.5,·jUtM 0Standard Plan 0 Expanded Plan
o Commercial Drivers Legal Plan ($25Enrollment Fee)o Law Officers Legal Plan 0 Exp. Law Officers Legal Plan
o Home-Based Business Plan (1st time enrollee)o HBBRider only (must be same payment method as Expanded Plan)
o Legal Shield 0 Other' _
'Some plans maynot be available incertain states.A $10 non-refundable fee is required for individual enrollments.
IRO
member informationPlease print.
~ / ~ / ~ If you choose the bank draft option,U-.-J U-.-J ~ your account will be drafted 011 orMonth Day Year about this date each month.
~ ~ ~ Forinternaluseonlyby~ - U-.-J - ~ PPLSI.Ourpnvacypollcyis available upon request.
AssignedAssociateNumber _
AssociateName _
AssociateSSN Number(lfLicensed) _
Associate License Number(ln Florida) _
_ BusinessPhone _
Signature of Associate X
Today's Date
SSN#
Name Last
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 understandthat the company will mail the written contract to me at the address noted herein within the nextfourteen days. If I have not received my contract within that time frame. I understand that it is myresponsibility to call the Pre-Paid Legal Home Office at 1-800-654-7757 to obtain a copy. Thewritten contract, together with this application. constitutes the entire agreement between thecompany 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 themembership contract.
In Rorida, any person who knowingly and with intent to injure, defraud, or deceive any insurerfiles a statement of claim or an application containing any materially false. incomplete. ormisleading information concerning a material fact is guilty of a felony of the 3rd degree.
First
Mailing Apt. /Address Ste.#
StreetAddress _
City
State ZIP + 4
Member's OJ/OJ/~Date of Birth ~
Month Day Year
Spouse LastI hereby acknowledge that on this date, I purchased this plan in the city of____________ in the state of . By signing this applicationI certify I am legally residing in the United States of America.
MIFirst
UTI-UTI-LlllJ Ext. ITIIJUTI -UTI-LlllJ
Work PhoneSignature of Applicant.=.X-"-- _
Home Phone / /DependentsLast / First / MI Dateof Birth
/ /EmailAddressLast / First / MI Date of Birth
/ /CJ I do 110twish to receive email updates from PPLSI about my membership.
(Your privacy is a priority with us! PPLSI uiill not sell your email addressor personal information of any kind to third party vendors.) Last / First / MI Date of Birth
paym en t info rma tion TO COMPLETE, selecUhe ONE payment option you prefer. Your credit card charge or check is yourreceipt.
oMonthly or Annual Bank DraftAuthorization 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 eachmonth on or about the effective date of your membership.
Please fill out for Bank Draft orCredit Card payment options:
$DIIIJ$[0]]
Monthly/Annualdraft/Charge amount
One-time enrollment feeAcct. # _
Institution Transit # -----------------------------Signature of Account Holder=-X=--- _
o Checking Account 0 Savings Account(Attach check from account to be drafted.) (Attach verification.)
Name of Bank _
(FinancialInstitution)Bank Address _
Totalenclosedbycheck, moneyonler,orchargedtocreditcanl $DIIIJ(If paying by credit card, I realize my first charge willinclude a one-time enrollment fee where applicable.)CITY ZIPSTATE
oMonthly or Annual Payment by Credit CardIwish to pay by credit card until I revoke this authorization in writing. I realize my account will be charged on or about the 15th or 25th monthly.
Exp. Date: [UJJ (Mo.jYr.)
[JAnnual Direct BillI wish to pay annually by check.Checks should be made payable toPre-Paid Legal Services,lnc.Card #:
Amountenclosed: _
o MasterCard 0 Visa 0 Discover 0 AMEX *Mustincludefirstyearpayment.Cardholder' Signature: X~--------------------------
APP.UNI(7.02) .50994 ©2002 Pre-PaidLegalServices", lnc., Ada,OK
