Employee Benefit Plans
Enrollment Form

Thank you for your decision to join Legal Club of America.  Please take a moment to fully complete the information below.  If you decide to change any information after entering your data, highlight and re-enter the data, or click the "Clear Form" button at the bottom to reset the entire form.

A well executed benefits offering will maximize an employee's perception of their employer.  Choosing the proper enrollment method and proper communication is paramount to successful benefit implementation.  Education and employer cooperation are the keys to any successful benefit enrollment.

The following information will be used to tailor an enrollment plan to your individual needs, as well as those of your employees.  It is our goal to educate all employees on the benefits being offered and to maximize employee participation.  It is important to remember that a benefit is only truly a benefit if your employees take advantage of it.

Applicant Information

* - These fields are required.

* Business Name:
* Last Name:
* First Name:
* Social Security/Federal ID #:
* Date of Birth:
* Street Address 1:
  Street Address 2:
* City:
* State:
* Zip Code:
* Business Telephone:
* Home Telephone:

  Fax Number:

* Email Address:


Census Information

* Plan Type:
* Enrollment Type:
* Number of Employees:
* Proposed Effective Date:


This form only serves to notify us that you are interested in our Legal Club Employee Benefits Plan.  Membership will not begin and you will not be billed.  This form is used simply to provide us with information about your company and employee census data so that we may contact you regarding membership.

Yes, I want more information about enrolling my company in Legal Club of America�.  I understand we will have access to all the services and benefits outlined on the web site, subject to the terms and conditions in the Plan Member Guidebook.  Upon enrollment, I will have 30 days to cancel my membership.  The plan is not party to any confidential relationship which I may establish with any participating attorney.  I understand that this plan is not insurance coverage.  I understand that costs and filing fees are additional.



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Last modified: May 12, 2015