Enrollment Form

Registration Type Individual
Group: Enter your company's name
Cost per month:
About You

Contact Information

Dependent Information

Other Dependents
Full Name Relationship Date of Birth
Law Firm
(see full list)
Payment Information


I hereby apply for enrollment in the UNITED LEGAL BENEFITS ("ULB") legal services plan. I have received a copy of the Plan Agreement ("Agreement") and understand the coverages, exclusions, limitations, and other provisions of the plan.

I understand and agree that the Agreement shall be effective upon the acceptance of this application (the "Commencement Date"). Through my credit card, I agree to pay the monthly fee for twelve (12) months and I understand that I am obligated to be a member of ULB for a minimum of 12 months.

I understand and agree that if this Agreement is canceled prior to the one-year anniversary of the Commencement Date for any reason, I will be liable to ULB for the balance of monthly fees due for the remainder of the twelve (12) month period. ULB shall be entitled to reasonable attorneys' fees and/or collection expenses to enforce the Agreement. Renewal of coverage following termination is subject to a twelve (12) month waiting period.

I understand that payment is due in advance and that if ULB does not receive payment within ten (10) days from the due date, ULB has the right to cancel the Agreement and shall have no further obligations to me.

I represent that all of the information furnished by me is true and correct and acknowledge that any pre-existing litigation, court proceedings, or other legal actions by or against any person covered by the Agreement shall not be covered, except as expressly provided in the Agreement.

This Agreement shall automatically renew annually on the anniversary of the Commencement Date unless ULB is notified in writing thirty (30) days prior to any such date.