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Applicant Information

Company Association :
* First Name :
* Last Name :
* Employee ID # :
Spouse First Name :
Spouse Last Name :
* Address :
* City :
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* Home Phone :
Work Phone :
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Any person who knowingly with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree.  I understand that legal services will be provided as outlined in the contract and that I will be responsible for any filing fees, court costs, etc. associated with any action. I authorize for a monthly service fee to be collected as indicated above or by any other method should I change to in the future.  I understand that the attorney-client relationship is confidential and such relationship is with my assigned attorney and not with U.S. Legal. I represent that to the best of my knowledge, all information above is true and correct and that no person to be insured under the plan is now involved in any litigation, court proceeding, or other matter which could result in legal action. This Plan shall be effective from the first date a Plan Member makes the initial monthly contribution to the Plan and such contribution is accepted at the Plan’s home office.  Example:  If your initial monthly payment is made on a weekend or after 5:00 p.m. EST on a week night, said payment will not be processed until the next business day.  Your plan will not be effective until your payment has been processed.

By affixing my name to the box below I agree to abide by all terms and conditions set forth by U.S. Legal Services, Inc.

*Electronic Signature :				5/7/2024 7:20:44 AM
			(Type Full Name)