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LegalShield Membership Form

Last 4 of Social Security Number

* required

* required

Personal Information:

Choose One Plan:

IDShield Plan

LegalShield Plan

Both LegalShield and IDShield

IDShield Plan

LegalShield Plan

Both LegalShield and IDShield

Family:

Individual:

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:

$10.95/mo

$20.95/mo

$31.90/mo

$20.95/mo

$20.95/mo

$38.90/mo

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