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INDEPENDENT PLAN APPLICATION
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
First Name
Last Name
Address 1
Address 2
City
State
Zip
Plan Type
SECURE PLAN
Type
NEW ENROLLMENT
SELECT ONE
Single
Family
Dependent 1 First Name
Dependent 1 Last Name
Dependent 1 Relationship to Applicant
Dependent 1 Gender
Dependent 1 DOB
Additional Dependent?
[Choose one]
Yes
No
Dependent 2 First Name
Dependent 2 Last Name
Dependent 2 Relationship to Applicant
Dependent 2 Gender
Additional Dependent?
[Choose One]
Yes
No
Dependent 3 First Name
Dependent 3 Last Name
Dependent 3 Relationship to Applicant
Dependent 3 Gender
Additional Dependent?
[Choose One]
Yes
No
Dependent 4 First Name
Dependent 4 Last Name
Dependent 4 Relationship to Applicant
Dependent 4 Gender
Select Plan
SINGLE ANNUAL $270
FAMILY ANNUAL $435
SINGLE MONTHLY $28
FAMILY MONTHLY $45
Payment Method
BANK DRAFT OPTION
CREDIT CARD OPTION
BANK ACCOUNT NUMBER
9-DIGIT BANK ROUTING NUMBER
RECURRING PAYMENT FREQUENCY
Monthly
Annually
ACCOUNT TYPE
Checking
Savings
BANK NAME
BANK DRAFT CUSTOMERS PLEASE COMPLETE BANK INFORMATION ON THIS FORM
By signature of this application, you hereby authorize Texas Legal to charge/draft your checking/savings account from the financial institution listed. This is a recurring monthly or recurring annual option. This authority is to remain in effect until Texas Legal receives written notification from you revoking the authorization, subject to the terms and restrictions provided in the Policy. This account will be drafted at the beginning of each month. Payment is due on the 1st of each month. Your account may not reflect the debit until the 2nd and later depending on the bank or credit union transactions or guidelines. Each financial institute establishes its own guidelines.
** NOTICE: RETURNED BANK DRAFTS INCUR $25 FEE **
CREDIT CARD CUSTOMERS PLEASE COMPLETE CREDIT CARD INFORMATION ON THIS FORM
I hereby authorize Texas Legal to charge the credit card below for a monthly payment of my premium or due fees, depending on my selection. I certify that I am the authorized holder and signer or have the consent of the authorized holder and signer of the credit card referenced above and that all information above is complete and accurate. I understand that this information will be securely maintained.
** NOTICE: DECLINED CREDIT CARDS INCUR $25 FEE **
Cardholder Name
Billing Address
City
State
Zip
Credit Card Number
I understand that Texas Legal will contact me via the phone number I listed above when this application is received to obtain credit card information.
Authorization
I understand that Texas Legal Protection Plan, Inc. d/b/a Texas Legal ("Texas Legal") sets forth the terms on my membership, including any exclusions or limitations, and agree to be bound by the same. The Secure Plan Independent Policy for Legal Services ("Independent Plan"), Schedule of Benefits, Declarations Page, and this application constitutes the entire agreement between Texas Legal 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 those documents. Please honor payment option listed above or below on my account by Texas Legal to its own order.
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