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LegalShield Membership Form

Last 4 of Social Security Number

Personal Information:

Choose One Plan:

Family:

Individual:

$12.95/mo

$21.95/mo

$22.95/mo

$34.90/mo

$41.90/mo

Select Supplements:

None

Gun Owners Legal Plan

(+12.95/mo)

Payroll Deduct:

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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