CLASSIC MEMBERSHIP
ENROLLMENT FORM
TERMS & CONDITIONS - Legacy Safeguard is a legacy and end of life planning consumer advocacy service provided by Legacy Safeguard, LLC. Member
understands and agrees that by completing and returning this enrollment form the Member will receive a limited free online membership in the Legacy Safeguard
service. Legacy Safeguard is not an insurance policy. Actual fees and charges associated with a funeral or other related services offered are not covered by Legacy
Safeguard. This is a free benefit and provided to the recipient at no additional cost; this offer is subject to change without notice. Member may choose to purchase
additional services, including but not limited to, additional membership opportunities in Legacy Safeguard. Member also agrees that they can be contacted by
Legacy Safeguard at anytime to receive additional information about merchandise and services offered by Legacy Safeguard, its affiliates and other companies that
Legacy Safeguard partners with. Member agrees to indemnify, defend, and hold harmless Legacy Safeguard, its affiliates, officers, agents, contractors, and
employees, from any claim arising in any manner, directly or indirectly, out of or in connection with terms of this agreement or any other agreement between the
parties to this agreement regardless of the cause of fault or failure to comply with any of the provisions of the aforementioned agreement, which includes, but is not
limited to, the negligence of either party to this agreement. Member further agrees to indemnify, defend, and hold harmless Legacy Safeguard, its affiliates, officers,
agents, contractors, and employees from any and all claims and/or causes of action set forth by or against Member and/or a third-party for the actions or omissions
of Member and/or any third-party that arises out of or are any way connected with that which is addressed herein.
Members Name Date of Birth (MM-DD-YYYY) Gender
Spouse’s Name Date of Birth (MM-DD-YYYY) Gender
Address
City State Zip Code
Phone Number Email Address
M F
M F
Signature Date (MM-DD-YYYY)
Simple Enrollment Process
Legacy Safeguard can help you leave a lasting legacy and provide your family with end of life planning, guidance and
assistance, at the time of need. To receive your complimentary membership in Legacy Safeguard please complete, sign
and return the enrollment form below to take advantage of all the membership benefits.
I have read and agree to the Terms & Conditions of Legacy Safeguard and I understand that membership is voluntary.
Member Information
Agent’s Name
Phone Number Email Address
Insurance Company Name Agent Number
Agent Information
Acknowledgement of Terms & Conditions
LEGACY SAFEGUARD name, design and related marks are trademarks and property of Legacy Safeguard, LLC © 2011 Legacy Safeguard, LLC. All rights reserved.
LS073_C2311
Return by mail: Legacy Safeguard • P.O. Box 270523 • Flower Mound, TX • 75027 Return by email: enrollment@legacysafeg
uard.org Return by fax: 214-224-0922
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