2890

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LegalShield Enrollment Form

Last 4 of Social Security Number

Personal Information:

Choose One Plan:

IDShield Plan

LegalShield Plan

Both LegalShield and IDShield

IDShield Plan

LegalShield Plan

Both LegalShield and IDShield

Family:

Individual:

$8.45/pp

$15.95/pp

$24.40/pp

$12.95/pp

$15.95/pp

$28.90/pp

Payroll Deduction Authorization:

I hereby Authorize my employer listed above to deduct the selected plan price each month from my earnings for my LegalShield/IDShield Membership and to remit such amount directly to LegalShield.

Your Signature

Family Information:

Spouse/Significant Other:

Children:

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