Individual/Family Protection Plan

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.

Applicant Information

* - These fields are required.

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

  Fax Number:
* Email Address:


Spousal Information

   Spouse's Name:
   Social Security #:


Dependent Information

Child 1 Name and DOB:

Child 2 Name and DOB:

Child 3 Name and DOB:

Child 4 Name and DOB:

Child 5 Name and DOB:


Additional Dependents:


Comments:


Payment Information

 
Credit Card:
Visa
Master Card
Discover
American Express
Card #: 
         
Expiration (mm/yy):
 
Payment Mode:

Annually ($168.00)
Quarterly ($42.00)

        

ACH (Direct Payment):

Monthly Bank Draft ($14.00)
 
Bank Name:
Street Address:
City/State/Zip:
Routing #:
Account #:

Yes, I want to enroll in the Legal Club of America� Individual/Family Protection Plan. The annual membership fee is only $168.00 per year for my family.  I will have access to all the services and benefits outlined on the web site page, 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.

By clicking "submit" you are representing and acknowledging that you are authorized to use the credit card listed above.

    


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Last modified: May 12, 2015