INDEPENDENT PLAN APPLICATION - Texas Legal Services

Independent Plan Enrollment

An Independent Plan is one purchased directly by the consumer from Texas Legal and is not made available to consumer by virtue of his/her status as an employee or his/her status as an association member of an organization that sponsors Texas Legal plans.

How did you become aware of Texas Legal?
My EmployerAn Association/Affiliation or Other GroupThe InternetAdvertisingFriend, Family or Colleague ReferralOther

Are you a Veteran?
YesNo

Please contact visit https://texaslegal.org/join, as you may qualify for association coverage.

This plan is made available to me by:
Group I: My EmployerGroup II: Association/Affiliation or Other GroupIndependent: Not part of a Group as defined above

Independent Plans may be purchased from Texas Legal by any Texas resident. Group Plans are made available to employees or associate members of any organization that sponsors Texas Legal and has a Texas Legal Group Master Policy.

Please tell us the name of the employer or Association/Affiliation/Group with whom you are employed or associated.

Employer or Association/Affiliation/Group Name

Please tell us the name of the employer or Association/Affiliation/Group with whom you are employed or associated.

Employer or Association/Affiliation/Group Name

Personal Info

Your First Name

Your Middle Name

Your Last Name

Date of Birth

Your email

Mailing Address

Unit/Apt No.

City

State

Zip

Primary Phone

Secondary Phone

Type of Coverage

Select One
IndividualFamily

Individual Plan

*Complete Dependent Information

Dependent Information

Dependent 1

Your First Name

Your Middle Name

Your Last Name

Date of Birth

Relationship to Applicant

Do you wish to add another dependent?
YesNo

Dependent 2

Your First Name

Your Middle Name

Your Last Name

Date of Birth

Relationship to Applicant

Do you wish to add another dependent?
YesNo

Dependent 3

Your First Name

Your Middle Name

Your Last Name

Date of Birth

Relationship to Applicant

Do you wish to add another dependent?
YesNo

Dependent 4

Your First Name

Your Middle Name

Your Last Name

Date of Birth

Relationship to Applicant

Do you wish to add another dependent?
YesNo

Dependent 5

Your First Name

Your Middle Name

Your Last Name

Date of Birth

Relationship to Applicant

Notice of Rates and Payment Method

RATES	SINGLE ANNUAL	FAMILY ANNUAL	SINGLE MONTHLY	FAMILY MONTHLY
SECURE PLAN	$250.00	$385.00	$26.00	$40.00

Which payment option would you like?

Bank DraftDebit/Credit Card

BANK DRAFT OPTION	BANK ACCOUNT NUMBER	BANK ROUTING NUMBER
RECURRING PAYMENT FREQUENCY MonthlyAnnual	ACCOUNT TYPE CheckingSavings	BANK NAME
BANK DRAFT CUSTOMERS PLEASE COMPLETE BANK DRAFT INFORMATION ON THIS FORM NOTICE: RETURNED BANK DRAFTS INCUR A $25 FEE By submitting this application, you hereby authorize Texas Legal to charge/draft your checking/savings account from the financial institution listed. This is a recurring monthly or recurring annual option. This authority is to remain in effect until Texas Legal receives written notification from you revoking the authorization, subject to the terms and restrictions provided in the Policy. This account will be drafted at the beginning of each month. Payment is due on the 1st of each month. Your account may not reflect the debit until the 2nd and later depending on the bank or credit union transactions or guidelines. Each financial institute establishes its own guidelines.

CREDIT/DEBIT CARD OPTION	CARD TYPE VisaMastercardDiscoverAmerican Express
CARDHOLDER NAME	CARD NUMBER	EXP. DATE	CVC NUMBER
BILLING ADDRESS	CITY	STATE	ZIP
NOTICE: DECLINED CREDIT CARDS INCUR A $25 FEE By submitting this application, you hereby authorize Texas Legal to charge/draft your checking/savings account from the financial institution listed. This is a recurring monthly or recurring annual option. This authority is to remain in effect until Texas Legal receives written notification from you revoking the authorization, subject to the terms and restrictions provided in the Policy. This account will be drafted at the beginning of each month. Payment is due on the 1st of each month. Your account may not reflect the debit until the 2nd and later depending on the bank or credit union transactions or guidelines. Each financial institute establishes its own guidelines.

AUTHORIZATION I understand that Texas Legal Protection Plan, Inc. d/b/a Texas Legal ("Texas Legal") sets forth the terms on my membership, including any exclusions or limitations, and agree to be bound by the same. The Secure Plan Independent Policy for Legal Services ("Independent Plan"), Schedule of Benefits, Declarations Page, and this application constitutes the entire agreement between Texas Legal and the member with respect to the membership, and there are no agreements, understandings, warranties or representations other than as set forth herein and in those documents. Please honor payment option listed above or below on my account by Texas Legal to its own order.