LegalShield Membership Form

Last 4 of Social Security Number

Personal Information:

Choose One Supplement:









Select Plan:

Select One Payment Option:

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

Account Type

Family Information:

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