Fillable Form 4: EMPLOYEE BENEFIT MEMBERSHIP APPLICATION (Kellogg Community College)

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Form 4: EMPLOYEE BENEFIT MEMBERSHIP APPLICATION (Kellogg Community College)

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The Form 4: EMPLOYEE BENEFIT MEMBERSHIP APPLICATION (Kellogg Community College) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Kellogg Community College

BROWSE KELLOGG COMMUNITY COLLEGE FORMS

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Time of Day A.M. P.M.
EMPLOYEE BENEFIT MEMBERSHIP APPLICATION
CWA PLAN
MODE GR#
FOB FRAN
OFFICE USE ONLY
/ /
MM DD YYYY
• Pre-Paid Legal Services, Inc.
• Pre-Paid Legal Casualty, Inc.
• Legal Service Plans of Virginia, Inc.
• Pre-Paid Legal Services, Inc. of Florida
• Pre-Paid Legal Access, Inc.
Select Applicable Subsidiary:
Corporate Oces: One Pre-Paid Way • Ada, OK 74820
www.LegalShield.com • 800-654-7757
LegalShield is the trade name of Pre-Paid Legal Services, Inc. and its subsidiaries.
Toda
y’s Date
Please Choose plan:
Personal Information
The information you provide on this application is considered
non-public information, and LegalShield takes care to protect your information.
Applicant’s SSN
DOB
/ /
For Internal Use Only
City State Zip + 4
Apt.#/Ste#
Phone #
Business Ext. Home Cell
( ) ( ) ( )
MM DD YYYY
Please indicate below, on a voluntary basis, if you are either blind or deaf.
All information will be kept confiden-
tial, and used only to enhance the services provided by LegalShieId to its blind and/or deaf associates and members.
Blind Deaf
1
(**Your privacy is a
priority with us! We will
not sell your email
address or personal
information of any kind
to third party vendors.)
Last First MI
Last First MI
(*Co-Applicant refers
to Spouse or Domestic
Partners, Civil Union
Partners, Same-Sex
Partners, or other term
specifically defined by
any local, state or
federal statute.)
Applicant’s Name
*
C
o-Applicant’s Name
Address
**
Email
**
Email
Associate Use Only
Associate Name
Last First MI
Associate SSN
(If Licensed)
Associate Lic. #
(In Florida)
Assigned Assoc. # Bus. Phone
( )
Associate Signature
X
APP.PD (1.14)
Producer Identification Name/Number
Please print LEGIBLY in ALL CAPITAL letters, using ONLY BLUE or BLACK INK.
A $10 non-refundable fee ($25 for CDLP) is waived due to your employer offering this at work.
Individual IDShield - $3.00 Employer Paid
Family IDShield - $14.50/$11.50 Payroll Deduction from Employee
PB
4
203575
Please return completed form to Human Resources
Any questions, contact Vicki Rivera or Karen Rutenber
2
Employer
Occupation
Signature of Applicant
X
Dependent Information
Payroll Deduction Authorization
3
Applicant’s Name
Last First MI
Today’s Date
Applicant’s SSN
For Internal Use Only
/ /
MM DD YYYY
I hereby authorize
(Company Name)
City State
per (Circle one: week / month / other ) from my earnings for my
LegalShield, and subsidiaries membership and to remit such amount directly to LegalShield. I agree
that the company will not be responsible or liable for my decision to purchase the LegalShield
membership or the services provided through my membership and that company’s sole responsibility
is to withhold and pay my membership fee to LegalShield.
to deduct
$
.
If you have more than five (5) dependents, please
attach a separate piece of paper.
APP.PD (1.14)
DOB
Name
/ /
MM DD YYYY
Last First MI
DOB
Name
/ /
MM DD YYYY
Last First MI
DOB
Name
/ /
MM DD YYYY
Last First MI
DOB
Name
/ /
MM DD YYYY
Last First MI
DOB
Name
/ /
MM DD YYYY
Last First MI
Signature of Applicant
In AL, any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof. In FL, any person who knowingly and with intent to injure, defraud, or
deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information
is guilty of a felony of the third degree. In NJ, any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties. In OR, any person who knowingly, and with
intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete,
or misleading information concerning a material fact may be subject to criminal or civil penalties and/or cancellation of the
contract. In TN, it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Applicant: I understand 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 the company will send me the membership contract
within the next 14 days. If I have not received my contract within that time frame, I understand it is my responsibility to
call LegalShield 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,
or representations other than as set forth herein and in the membership contract.
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 and agree to the
above Authorization of Payment and membership fees selected above.
X
X
Account Holder’s Signature
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Form 4: EMPLOYEE BENEFIT MEMBERSHIP APPLICATION (Kellogg Community College)

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Completed 18 September 2020

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