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THE NORTH CAROLINA STATE BAR ANNUAL REPORT FOR (North Carolina State Bar)

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File type: PDF

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THE NORTH CAROLINA STATE
BAR
ANNUAL REPORT FOR REGISTERED PREPAID LEGAL SERVICES PLAN
The North Carolina State Bar requires, pursuant to 27 N.C. Admin. Code Chapter 1, Subchapter E,
§ .0307 of the North Carolina State Bar Regulations for Organizations Practicing Law, that each prepaid
legal services plan registered to operate in North Carolina submit a registration renewal every year. The
provisions of 27 N.C. Admin. Code Chapter 1, Subchapter E, § .0307 of the North Carolina State Bar
Regulations for Organizations Practicing Law hold that a prepaid plan may not continue to operate in
North Carolina if its annual renewal is not accepted by the North Carolina State Bar on or before
January 31 of each year.
Accordingly, this form and any accompanying documents must be completed and
submitted to the North Carolina State Bar no later than December 1 so that the application can be
reviewed and a determination made regarding its acceptance by the January 31 deadline.
Mail or email this report to:
Secretary of the North Carolina State Bar
c/o Savannah B. Perry, Deputy Counsel
North Carolina State Bar
PO Box 25908
Raleigh, NC 27611
sperry@ncbar.gov
Plan Name:
Plan Number:
Date:
Are there any changes you wish to make to your plan?
□
Yes
□
No
If “No,” please leave the rest of the document blank, save for the certification on page 3. If
“Yes,” please only complete the portions below that you wish to change this coming year.
Please note that if you wish to change any of the information listed below, you must
indicate it here and complete and file a separate amendment form.
1. New Name of Legal Services Plan:
2. New Name of Plan Sponsor:
3. New Name of Registered Agent of Plan or Entity Owning Plan in North Carolina:
__
4. New Name of Plan Administrator:
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5. Names, addresses, and telephone numbers of all new attorneys responsible for furnishing legal
services in the plan:
6. This registration includes attachments detailing the following information: (check if applicable)
□
New terms of the legal services plan
□
New schedule of benefits
□
New subscription charges
□
New participating attorney agreement
7. New Address of Plan:
8. New Telephone Number of Plan:
9. New Address of Registered Agent of Plan or Entity Owning Plan in North Carolina:
10. New Telephone Number of Registered Agent of Plan or Entity Owning Plan in North Carolina:
11. New Address of Plan Administrator:
12. New Telephone Number of Plan Administrator:
13. New person to be contacted by the North Carolina State Bar:
14. New address of person to be contacted by the North Carolina State Bar:
15. New telephone number of person to be contacted by the North Carolina State Bar:
16. If you made any amendments to your plan since its last annual report to the North Carolina State Bar
that are not indicated herein, please attach copies of your amendment forms and the letter from the
North Carolina State Bar accepting your amendments to this report and indicate in the box provided
if any amendments are attached.
□
Amendment materials are attached
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17. If you are using any new sales brochures, pamphlets or other advertising materials to market your
plan, please attach copies of them to this report and indicate in the box provided if any materials are
attached.
□
New advertising materials are attached
I certify that the information contained herein is true and correct to the best of my knowledge. I am
aware that any amendments to this plan or to any documents required to be filed upon registration of the
plan shall be filed with the North Carolina State Bar on a form provided by the North Carolina State Bar
within 30 days of the adoption of the amendment. A check for the annual registration fee of $100.00,
made payable to the North Carolina State Bar, is enclosed. I understand that the annual
registration fee is non-refundable.
Date Signature
Type or Print Name
Title
Address
Phone Number
Amended 9/2018
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THE NORTH CAROLINA STATE BAR ANNUAL REPORT FOR (North Carolina State Bar)

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Completed 20 July 2020

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