INDEPENDENT PLAN APPLICATION

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?

    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.

    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.

    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.



    Personal Info


    Type of Coverage

    Select One
    IndividualFamily

    Individual Plan
    *Complete Dependent Information

    Dependent Information


    Dependent 1


    Do you wish to add another dependent?
    YesNo


    Dependent 2


    Do you wish to add another dependent?
    YesNo


    Dependent 3


    Do you wish to add another dependent?
    YesNo


    Dependent 4


    Do you wish to add another dependent?
    YesNo


    Dependent 5


    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.