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LegalShield Membership Form

Last 4 of Social Security Number

Personal Information:

Choose One Plan:

Family:

Individual:

$1.95/pp

$3.45/pp

$3.68/pp

$3.68/pp

$5.40/pp

$6.67/pp

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:

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