PrePaid Legal Application Form

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Office Use Only membership application Pre-Paid Legal Services ® , Inc., and subsidiaries Corporate Offices: P.O. Box 145 " Ada, OK 74821-0145 CWA FOB MODE PLAN FRAN GR# Please print. For internal use only by PPLSI.

Our privacy policy is available upon request. Last First MI Apt. / Ste.# City State ZIP + 4 member information SSN # Name Primary Member's Date of Birth Spouse Mailing Address Work Phone Home Phone Today's Date payroll deduction authorization Last First MI -- Ext.

-- // // Email Address Street Address Month Day Year Month Day Year I hereby authorize my employer______________________________ City ____________________ State _____ to deduct $_____________ per month from my earnings for my Pre-Paid Legal Services ® , Inc., and subsidiaries membership and to remit such amount directly to Pre-Paid. I agree that my employer will not be responsible or liable for my decision to purchase the Pre-Paid membership or the services provided through my membership and that my employer's sole responsibility is to withhold and pay my membership fee to Pre-Paid. X APP.PD (6.02) " 23386 ©2002 Pre-Paid Legal Services ® , Inc., Ada, OK Time of Day A.M.

P.M. (Circle One) EMPLOYEE BENEFIT A $10 non-refundable fee is required for individual ... more. less.

enrollments. - - Last / First / MI Date of Birth Last / First / MI Last / First / MI Date of Birth Date of Birth Dependents Employer Occupation I hereby acknowledge that on this date, I purchased this plan in the city of ________________________________ in the state of _________. By signing this application I certify I am legally residing in the United States of America. X Signature of Applicant Assigned Associate Number_________________________________________________ Associate Name___________________________________________________________ Associate SSN Number (If Licensed)___________________________________________ Associate License Number (In Florida)_________________________________________ Business Phone___________________________________________________________ Signature of Associate______________________________________________________ X Associate Use Only Standard Plan Expanded Plan Commercial Drivers Legal Plan ($25 Enrollent Fee) Law Officers Legal Plan Exp. Law Officers Legal Plan Home-Based Business Plan (1st time enrollee) HBB Rider only (must be same payment method as Expanded Plan) Legal Shield Other* _____________________________ Pre-Paid Legal Services ® , Inc. Pre-Paid Legal Casualty TM , Inc. Pre-Paid Legal Services of Tennessee, Inc. Pre-Paid Legal Services, Inc. of Florida National Pre-Paid Legal Services of Mississippi, Inc. Legal Service Plans of Virginia, Inc. Ohio Access to Justice, Inc. administered by Pre-Paid Legal Services ® , Inc. CHECK ALL THAT APPLY* CHECK ONE Pre-Paid Legal Services, Inc., Associate Use Only *Some plans may not be available in certain states. IR Print name _______________________________________________SSN___________________________________ Date ____________________ Applicant signature: ____________________________________________________ Applicant: I understand that the written contract sets forth the terms of my membership, including any exclusions or limitations, and agree to be bound by the same. I further understand that the company will mail the written contract to me at the address noted herein within the next fourteen days. If I have not received my contract within that time frame, I understand that it is my responsibility to call the Pre-Paid Legal Home Office at 1-800-654-7757 to obtain a copy. The written contract, together with this application, constitutes the entire agreement between the company 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 the membership contract. In Florida , any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any materially false, incomplete, or misleading information concerning a material fact is guilty of a felony of the 3rd degree. I do not wish to receive email updates from PPLSI about my membership. (Your privacy is a priority with us! PPLSI will not sell your email address or personal information of any kind to third party vendors.)

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