Enroll Now in Affordable Legal Insurance Plans by U.S. Legal

            Company: SEIU Local 721 CTW CLC
            Plan: Family Defender
            Premium: $13.14 per month

Fields marked with (*) are required.

Applicant Information

* SSN # :
* DOB :
* First Name :
MI :
* Last Name :
Spouse First Name :
Spouse Last Name :
* Address 1 :
Address 2 :
* City :
* State :
* Zip Code :
* Home Phone :
Work Phone :
* Email Address :		(Policy will be delivered to this email address)

I declare, under penalty of perjury, that the information provided in this application is true and correct to the best of my knowledge. 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. By submitting this application, I authorize for a monthly payment to be collected as indicated in this application or by any other method 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 Services. By submitting this application, I understand that U.S. Legal Services will deliver electronically, via email, both the Plan Policy and Member ID Card. I understand that the Plan Policy will be made available at www.uslegalservices.net. I understand that I have the option to receive a hard copy of the Plan Policy and can do so by contacting U.S. Legal Services at fulfillment@uslegalservices.net. Electronic delivery may be limited in some states; in those circumstances, U.S. Legal Services will deliver the Plan Policy via U.S. Mail. Not sponsored or approved by the United States Government or any Department or Agency thereof.

By signing this application you are acknowledging and authorizing SEIU 721 to deduct any necessary bi-weekly payroll deduction to cover any premium payments. I understand that once I am enrolled, I must remain on the plan until the next Open Enrollment period. I agree to abide by all terms and conditions set forth by U.S. Legal Services, Inc.

*Electronic Signature :				4/25/2024 7:29:51 AM
			(Type Full Name)

To Submit Your Application