Primerica LegaL Protection ProgramUnderwritten by Pre-Paid Legal Services, Inc.

Your Provider Law Firm Information:

Parker Stanbury LLP

Call Toll-Free: 1-800-526-8585

Out of State & Local Calls: 1-213-955-0001Spanish: 1-800-493-7964

Parker Stanbury, LLP began in 1927 when Harry Parker came West to begin practicing law in the State of California. In the years that followed, he was joined by such outstanding advocates and trial attorneys as Ray Stanbury, White McGee, Jr., and Dick Reese. These prominent attorneys formed the core of the sound and respected law firm that is Parker Stanbury, LLP. The tradition of excellent legal service and representation initiated by Mr. Parker and his partners continues through today.

The law firm of Parker Stanbury, LLP is a full service law firm providing legal service, advice and representation in many areas of the law. With its staff of highly experienced and knowledgeable attorneys, and growing professional support staff, the firm provides comprehensive legal service in the many areas of expertise.

Your Membership takes the Fear and Intimidation out of using a Lawyer. Most people have never used a lawyer, or have had limited contact with a law firm, and might be intimidated by doing so.

Tips for Working with Your Lawyer:We encourage you to use your membership!

• Review your membership guide, including your plan contract. Knowing your benefits will help you when speaking to your lawyer about your concerns and options.

• Communicate with your lawyer. It is important that you ask questions about your legal situation. Your lawyer is here to serve you and offer advice and counsel.

• Your Pre-Paid Legal lawyer should advise you before you make important decisions. Be sure to ask questions if any point remains unclear. You should clearly understand the options available in your situation.

• Please respect your lawyers judgment. Keep in mind that the law doesn’t always allow a resolution in your case that may be 100 percent satisfactory to you.

Parker Stanbury, LLP

• Appellate practice

• Administrative law

• Bankruptcy

• Business law

• Business litigation

• Civil appeals

• Civil litigation

• Construction and accident

detect

• Consumer law

• Corporation

• Criminal law

• Elder law

• Estate planning

• Family law

• First party claims

• General civil law

• Government liability

• Immigration

Parker Stanbury, LLP began in 1927 when Harry Parker came Westto begin practicing law in the State of California. In the years thatfollowed, he was joined by such outstanding advocates and trialattorneys as Ray Stanbury, White McGee, Jr., and Dick Reese. Theseprominent attorneys formed the nucleus of the sound and respected lawfirm that is Parker Stanbury, LLP. The tradition of excellent legal serviceand representation initiated by Mr. Parker and his partners continuesthrough the present.

The law firm of Parker Stanbury, LLP is a full service law firmproviding legal service, advice and representation in many areas of thelaw. With its staff of highly experienced and knowledgeable attorneys,and growing professional support staff, the firm providescomprehensive legal service in the following areas of expertise:

Call Toll-Free: 1-800-526-8585 Spanish: 1-800-493-7964

Direct and Local Calls: 1-213-955-0001

Parker Stanbury, LLPhas over 80 attorneys in

offices located inLos Angeles, Santa Ana,

San Bernardino, San Diegoand Sacramento.

• Medical malpractice

• Patent/copyright

• Personal injury

• Police liability

• Premises liability

• Probate

• Product liability

• Professional malpractice

• Public benefits

• Real estate

• Real property

• Social Security

• Tax

• Toxic Tort

• Traffic

• Transportation law

• Uninsured/underinsured

motorist

• Vehicle liability

• Employment/wrongful

termination

• Worker’s Compensation

• Insurance coverage

• Insurance defense

• Landlord/tenant

• Land subsidence

The law firm to call for your legal needs is:

The firm’s attorneys are experienced and passionate trial advocates.Our clients include insurance carriers, individuals, local businesses and professionals.

Your Provider Law Firm

Primerica Legal Protection Program

Objective

• Provide for immedi~e access 10 a respected, full-service law linn ilia will defend your legal rights, property andperson

Ask Yourself the following

Do you evor plan to._

Write or revi"" your will?

Purcha"" anew or used c,.-?

Purcha"" ahom.?

Havey"" ever...

Purcha""d a defective pro ducl?Received an unjustified traffic licket?

Signed a 1egally binding document?

Paid a bill you thought was unfair?Be.n a defend,.,tin a civil1aw;uil?

Worried about,., IRS ;ndil?

• If you a>s_,-"d yes 10 any of the questions above, the !'rimmea Legal. Protection Program is a quick and easy way10 access leg.. coun""ling and ,..-vi "" 10 help your family protecl it",,!f from exp ecled and unexpected legalproblem, for the low cost 0 f $2 5 a month

PLPP Protects your FNA Solutions

• While you","" positioning yourself 10 reach your FNA ""lulion~ the !'rimmea Leg.. Protection Program provide,you benefits ilia will help assi,t you in ,afegua-ding that which you h""e worked '0 hard to build

r::: InromeProtemon Solution Drot Managffilent Solution Savings Managffilent Solution.,

Provide' ""i,t,.,ce to help you Provide' phone call' ,.,d Provide' a will to protect yourwith e:;tae settlement,.,d letter' to be ,entto creditor, ""et, by allowing you toplanning. inC<lme tax concern', on your behalf ,pecifY,.no will be awa-dedbenelitpl,., eleclion~ "'cial various inherit,.,ce, a,,ecurity pro cess. conte,ted Provide' phone consultaion oppo,ed to the ,tae decidingprobae ,.,d more for infonnaion regarding your ,.no get' wha

right, when it come, to dealingProvide' legal ,ervice:; by the with creditor, Protect, your asset, from aProvider Law Finn ",ue happy", ciety"

~ 2008 Primo",. Pi".,..,i>! S.wi",

Will Questionnaire

If you don’t have a Will, you’re not alone.

Most of us are reluctant to talk about death,

but preparing your Will could be the most

important legal decision of your life. It em-

powers you to clarify your intentions, protect

your family, and make your own decisions

about how your estate will be handled.

Think it’s complicated? It’s really not.

Follow the simple steps on the back cover to

have your Will prepared.

Your Pr imer ica Lega l Protec t ion ProgramTM

Get Started!1 2 3 4 5 6

1) Full name (first, middle, last)

______________________________________________________________

All other names by which you have been known:

______________________________________________________________

Social Security Number __________________________________________

Membership Number ___________________________________________

Age _____ Date of Birth (DOB)___________ Sex Male Female

Are you a US citizen?* Y N If no, country of citizenship _________

2) Current residence

Street address ___________________________ City _________________

County or Parish __________________ ST __________ ZIP ____________

Home Phone ___________________ Work Phone ___________________

3) If you are married, your spouse’s full name

(first, middle, last, maiden) _____________________________________________

Spouse’s SSN _______________________ DOB ___________________

Date of marriage______________ Place of marriage _______________

Are you currently living with your present spouse? Y N

4) Do you and your spouse have a Prenuptial Agreement which identifies and disposes of separate spousal property? Y N N/A If yes, attach copy with any filing data.

* Non-citizen estate taxation varies from taxation for US citizens.

es • tate n. Everything that you own at your passing after payment of debts and taxes. You will make decisions regarding the percentage share of your estate that you wish to give to your beneficiaries. And if you wish, you may leave specific items of property (car, investments, heirloom, etc.) or sums of money to your beneficiaries.

will n. A document which provides who is to receive your property, who will administer your estate, who will serve as guardian of your children, if applicable, and other provisions.

peace of mind n. The wonderful feeling you get as a Primerica Legal Protection PlanTM member after having your Will prepared by a qualified law firm at a reasonable price.

WHAT YOU’LL NEED TO FILL THIS OUT:• Copy of your Prenuptial Agreement (if applicable)• Names and birthdates of your children and grandchildren (if applicable) • The name and contact information of the person you’ve chosen to be guardian of your child(ren), the trustee(s) of their estate, and your personal representative/executor• To best serve you in completing your Will for estate tax purposes, you’ll be asked to provide the approximate dollar amount of such items as: your home, other real estate, bank accounts, vehicles, retirement plans, life insurance policies, and debts such as mortgages, loans, medical or others over $5,000

W i l l Q u e s t i o n n a i r e • p 1 o f 6 y o u r w i l l • y o u r p e a c e o f m i n d • e m p o w e r m e n t • p l a n n i n g y o u r f a m i l y • y o u r f u t u r e • y o u r e s t a t e • y o u r l i f e

PLEASE PRINT

HELPFUL INFORMATION BEFORE YOU GET STARTED!• This Will Questionnaire is NOT your Will. It will help your Provider Law Firm prepare your Will. All questions applicable to you MUST be completed in their entirety in order to have your Will prepared.• If you need more space to answer a question, attach a separate sheet and indicate the question number to which it pertains. • If you have questions while filling out this form, don’t hesitate to call your Provider Law Firm at the number on your membership card. • If you need the number to your firm, call Customer Care at 1-800-426-9239 (7 am - 7 pm, Mon-Fri, Central Time).

In order to meet each person’s unique needs, you must each fill out a Will Questionnaire

for your information:MEMBER AND SPOUSE FILLING OUT A SEPARATE FORM

5) If either you or your spouse has been divorced, please answer the following. If not applicable, please go to question #6.

Date of marriage ________________________________________________

Date of divorce judgment _________________________________________

Court rendering judgment ________________________________________

Date of spouse’s death (if applicable) ________________________________

6) Have you or your spouse created any trusts or made gifts through trusts to others? If yes, describe and include a copy. If not applicable, go to question #7.

______________________________________________________________ 7) Do you or your spouse expect any inheritance? If yes, state from whom and how much. If not applicable, please go to question #8.

_____________________________________________________________

8) If you have children, including adopted children, state the following for each child. If you do not have children, please go to question #15.

9) a. Deceased biological or legally adopted children if applicable.

b. Deceased child’s living children if applicable:

10) If you have stepchildren, do you want them treated the same as your natural born or legally adopted children in your Will? Y N N/A If yes, state the following for each:

11) If you have grandchildren, state the following for each. If not, go to question #12.

Full name Son/Daughter Date of birth Parent’s Name

Full name Son/Daughter Date of death

Child of current marriage? (Y/N)

Living? (Y/N) Full name Parent’s Name Grandson /

Granddaughter DOB

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3

1

2

3

4

A great deal of personal information is requested in your Will Questionnaire. Without all of the information request-ed, your Provider Law Firm can’t ensure your wishes will occur or that the most comprehensive estate planning op-tions have been advised. All informa-tion you provide them will remain strictly confidential.

for your information

Dear Pre-Paid Legal,

I’m writing to thank you for your firm’s excellent preparation of my Last Will and Testament. [My lawyer] has been very professional, knowledgeable, and responsive to my calls and questions. Due to his excellent service, I am pleased to continue using Pre-Paid Legal and to recommend it to friends, family, and business associates.

Sincerely,Member, Florida

“”

W i l l Q u e s t i o n n a i r e • p 2 o f 6y o u r w i l l • y o u r p e a c e o f m i n d • e m p o w e r m e n t • p l a n n i n g y o u r f a m i l y • y o u r f u t u r e • y o u r e s t a t e • y o u r l i f e

Full name Son/Daughter Date of birth

Full name Male/Female Date of birth Parent’s Name

Halfway Point1 2 3 4 5 6

12) Are any of your children or other beneficiaries mentally or physically disabled or have special needs? Y N If so, note any special provisions:

_________________________________________________________

_________________________________________________________

If so, are they presently receiving, or do you anticipate that they may apply for, SSI benefits in the future? Y N Note: If you leave a bequest, not left to a qualified trust, the recipient might be disqualified from SSI benefits. 13) If your children are under age eighteen (18), state the following for the person you wish to act as their guardian (custodian) in the event of your death or in case of the joint death of you and your spouse (if married). You should obtain the consent of that person(s) before executing your will. If you do not have any minor children, please go to question #15.

Name(s)__________________________________________________

Address __________________________________________________

Relationship ______________________________________________

If at the time of your death the person(s) named above is/are unwilling to serve as guardian (custodian), please list an alternate:

Name(s)__________________________________________________

Address __________________________________________________

Relationship ______________________________________________

14) Do you want the appointed guardian also to be the trustee (conservator) of any assets inherited by the minor children? Y N

At what age would you like your children to take control from the trustee of any inherited assets? (Must be at least 18 years old.) _______ years old

If no, please list the person or entity you wish to act as their financial custodian. You should obtain the consent of that person or entity before executing your will.

Name(s)__________________________________________________

Address __________________________________________________

Relationship ______________________________________________

Please list an alternate in case this person is unwilling or unable to serve:

Name(s)__________________________________________________

Address __________________________________________________

Relationship ______________________________________________

guard • i • an n.A person lawfully invested with the power, and charged with the duty, of taking care of the person who is incapable of doing so because of age or other incapacity. Certain states do not allow anyone other than a biologi-cal parent to be appointed as guard-ian in the event of one parent’s death. Please call your Provider Law Firm for instructions for your state.

Note to Louisiana residents: Although the provision in a Will providing for a guardian of minor children is not binding in LA, it is highly persuasive in a proceeding for the appointment of a guardian and should be included in the Will of any person with minor children.

trus • tee n.A person appointed to manage the financial affairs of the one who is legally incapable of doing so because of age or other incapacity.

W i l l Q u e s t i o n n a i r e • p 3 o f 6 y o u r w i l l • y o u r p e a c e o f m i n d • e m p o w e r m e n t • p l a n n i n g y o u r f a m i l y • y o u r f u t u r e • y o u r e s t a t e • y o u r l i f e

15) Indicate how you want your assets to pass when you die.

Please check the ONE option you prefer:

Option A I want my assets to pass to my spouse and children as follows:

___________________________________________

___________________________________________

___________________________________________

Option B I am unmarried with children and want my assets to pass as follows:

___________________________________________

___________________________________________

___________________________________________

Option C None of the above. I want my assets to pass as follows:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

• If you leave to a named beneficiary real/immovable property which is mortgaged, that property will generally pass under your Will to the beneficiary subject to the debt secured by the mortgage. • If you wish to leave the property free and clear of the mortgage debt, you must include a provision in your Will directing the debt to be paid from the other assets of your estate, provided sufficient assets are available. Note: LA residents, contact your Provider Law Firm for information particular to your state.

If you own property jointly with another person as “joint tenants with right of survivorship,” your interest in that prop-erty will pass to the survivor upon your death. It will not pass according to the terms of your will. If you own property jointly with another person without right of survivorship, your interest in that property will pass according to the provisions in your will. Note: ID and LA residents, contact your Provider Law Firm for information particular to your state.

for your information:JOINT TENANTS WITH RIGHT OF SURVIVORSHIP

for your information:MORTGAGED PROPERTY

joint tenants with right of survivorship n.A single property owned by two or more persons, under one title, with equal rights to the property. At the death of one joint tenant, the prop-erty transfers to the surviving tenant.

• In equal shares to my children.• If one of more of my children predeceases me, that child’s share in my estate is distributed to his or her children in equal shares.• In the event all my children and descendents fail to survive me, I want my assets to be distributed as follows:

W i l l Q u e s t i o n n a i r e • p 4 o f 6y o u r w i l l • y o u r p e a c e o f m i n d • e m p o w e r m e n t • p l a n n i n g y o u r f a m i l y • y o u r f u t u r e • y o u r e s t a t e • y o u r l i f e

You should know that decisions you have already made regarding title to property will determine distribution of that property in the future. Will provi-sions cannot alter those decisions. A beneficiary designation is a binding contractual obligation and a Will provi-sion will not alter that designation.

Beneficiary designations in life insur-ance policies, retirement plans, annui-ties, bank accounts with a named “Due on Death” (DOD) beneficiary, etc., will determine who receives those moneys upon your death, not your Will.

• To my spouse, if surviving.• If my spouse predeceases me, my assets will be divided in equal shares to my children.• If any of my children predecease me, that child’s share shall be distributed to his or her children in equal shares. • In the event my spouse and all of my children and descendents fail to survive me, I want my assets to be distributed as follows:

for your information:BENEFICIARY DESIGNATIONS

ex • ec • u • tor n.also personal representative The person appointed in a Will by the testator (person making the Will) to carry out the terms of the Will.

fi • du • ci • ar • y bond n.A type of surety bond required by the court to be filed by executors, guardians, etc., to ensure proper performance of their duties as an executor. Typically waived, especially when a spouse or family member is appointed executor.

health care po • wer of at • tor • ney n.A legal document appointing a per-son the authority to make health care decisions on another person’s behalf.

phy • si • cians di • rec • tive n.also living will A legal document containing instruc-tions for physicians regarding your life support preferences.

16) Do you wish to disinherit any children or grandchildren? If so list their names here. If not applicable, please go to question #17. Note: In certain states it is not possible to completely disinherit a spouse or minor child. Please contact your Provider Law Firm for more information. _____________________________________________________________

17) Execution of a Will is the best way to determine how your property will be distributed. However, it cannot address important issues regarding health care decisions. Your Provider Law Firm will prepare a Health Care Power of Attorney and Physician’s Directive* at no additional charge if prepared with your Will. * In AL, an Advance Directive for Health Care

Who would you like to serve as your representative responsible for making sure your health care wishes are carried out?

Full name ___________________________________________________

Address ____________________________________________________

Please list an alternate in case this person is unwilling or unable to serve:

Full name ___________________________________________________

Address ____________________________________________________

18) If married and your spouse is still alive, do you want your spouse to serve as your personal representative/executor*? Y N * Louisiana & Missouri residents, see back cover.

Please list an alternate below. If not married or you wish to appoint someone other than your spouse, please indicate below. Note: If you wish to name a non-U.S. resident, please contact your Provider Firm.

Full name ___________________________________________________

Address ____________________________________________________

Please list an alternate in case this person is unwilling or unable to serve:

Full name ___________________________________________________

Address ____________________________________________________

Do you wish to waive the fiduciary bond requirement? Y N

Please indicate your wishes by checking one box below:

I want this person to be able to act on my behalf immediately. I want this person to be able to act on my behalf only upon certification by a doctor that I am no longer able to make decisions and act for myself.

19) Many people make special provisions for family heirlooms, jewelry, or other items of special value to be distributed to friends or relatives. If you have such property and would like to leave it to a specific person, please complete the following. Note: In question #15 you indicated how you would like your assets to pass. Please fill out question #17 ONLY if you desire items with specific or sentimental value be left to a specific person. (Include a separate sheet of paper if necessary.) Item Special Identifying Features Recipient

_____________________________________________________________

Almost Done!1 2 3 4 5 6

W i l l Q u e s t i o n n a i r e • p 5 o f 6 y o u r w i l l • y o u r p e a c e o f m i n d • e m p o w e r m e n t • p l a n n i n g y o u r f a m i l y • y o u r f u t u r e • y o u r e s t a t e • y o u r l i f e

Rather than including your funeral wishes in your Will, which often isn’t read until after your funeral, it’s best to make your wishes known to loved ones in writing prior to your death.

for your information:FUNERAL ARRANGEMENTS

20) List the estimated value of your assets as of today’s date. Include the dollar amount in the appropriate column(s).

21) List your estimated debt in each category as applicable. Include the dollar amount in the appropriate column(s).

Confirmation of information and instructions: I confirm the information provided by me in this form is complete and accurate and that the instructions I have provided reflect my wishes.

Signature _______________________________ Print name _______________________________

Date _____________________ Phone number to call if questions __________________________

a. Home

c. Checking, savings, or credit union accounts & certificates

1.

2.

V A L U E

A S S E T S

d. Automobiles & Other Vehicles e. Stocks, Mutual funds & other investments

h. Life Insurance Policies i. Miscellaneous

T O T A L S

D E B T S

a. Mortgages on home, car, etc. b. Signature Loan at Bank c. Medical or other expenses d. Other debts over $5,000

T O T A L S

You have now completed your Will Questionnaire! Please see instructions on

back for final steps on how to get your Will prepared.

W i l l Q u e s t i o n n a i r e • p 6 o f 6y o u r w i l l • y o u r p e a c e o f m i n d • e m p o w e r m e n t • p l a n n i n g y o u r f a m i l y • y o u r f u t u r e • y o u r e s t a t e • y o u r l i f e

b. Other real estate*

* Indicate whether in state or out of state.

If you have a taxable estate with a market value in excess of:

• $1,500,000 in 2004 and 2005 • $2,000,000 in 2006, 2007 & 2008 or • $3,500,000 in 2009 at the time of your death, your estate may be subject to estate tax at your death or later at the death of your spouse.

Your taxable estate may include all life insurance on your life and all joint ten-ancy property. Tax laws are constantly changing. If your taxable estate is larger than $1,000,000 you should consult with your Provider Law Firm regarding advanced tax planning tools available at a discounted rate.

Your estate could be subject to state inheritance tax even if it isn’t subject to federal taxation. Please ask your Pro-vider Law Firm for further clarification.

for your information:FEDERAL ESTATE TAXES

for your information:STATE INHERITANCE TAXES

Many people think that if their loved one had a Will prepared, they will be able to avoid the probate process. This is not necessarily the case. Please ask your Provider Law Firm for details about your state.

for your information:PROBATE

pro • bate n. The judicial determination of the validity of a Will.

f. Interest in a business g. Qualified retirement plans (e.g. 401k plan)

Individual Assets

Joint/Community Assets

Spouse’s Separate Assets

Joint Assets/Non-Spouse

Individual Debts

Joint/CommunityDebts

Spouse’s SeparateDebts

Joint Debts/Non-Spouse

* Louisiana & Missouri Residents: Under law, the Personal Representative serves with Court supervision. Certain actions can be taken by your Personal Representative only after obtaining Court approval, including the sale or transfer of any real estate which is part of your estate. However, you can waive certain Court supervision by electing “Independent Administration” of your estate. By electing “In-dependent Administration” the expenses associated with probate administration may be lessened. However, because there is less Court supervision, there is a greater chance of dishonesty by the Personal Representative and they must secure the service of an attorney on legal questions arising in connection with the administration of the estate.

Do you wish to elect “Independent Administration” for your estate? Y N

Contracts issued by Pre-Paid Legal Services®, Inc., and subsidiaries: Pre-Paid Legal CasualtyTM, Inc. • In TN: Pre-Paid Legal Services of Tennessee, Inc. • In FL: Pre-Paid Legal Services, Inc., of Florida • In MS: National Pre-Paid Legal Services of Mississippi, Inc. • In VA: Legal Service Plans of Virginia, Inc. • Ohio Access to Justice, Inc., administered by Pre-Paid Legal Services®, Inc.

Corporate Offices: One Pre-Paid Way • Ada, Oklahoma 74820 • Toll Free: 800.440.8857 • www.pplmbr.com

WILLQUEST.PLPP • 2.05 • © 2005 Primerica Financial Services

Will QuestionnaireYour Primerica Legal Protection Program

After completing the Will Questionnaire, mail it to your Provider Law Firm.

If you need to include additional information to this form, please include a separate sheet of paper. If you need your Provider Law Firm’s address, please call their number on your membership card, or call Pre-Paid Legal Customer Care toll-free at 1-800-426-9239. Use one stamp for each Will Questionnaire you send in.

They will prepare your Last Will & Testament based on the confidential information you provide in your Will Ques-tionnaire. If they need additional info from you while completing your Will, they’ll call you.

Your Provider Law Firm should mail you your completed Will within ten (10) business days of when they receive your completed Will Questionnaire.

You’ll also receive instructions from your Provider Law Firm on how to have your Will finalized.

Safeguard your will and make a copy for your executor.

Store your Will in a safe place with other important legal documents. Please remember that you—not your Pro-vider Law Firm—are responsible for the safekeeping of your Will.

1

2

3

To have your Will prepared:

Primerica Legal Protection ProgramTM

By signing below, I acknowledge that I have given the appplicant a copy of Primerica's privacy policy, "Your Privacy is Important to Us."

files a statement of claim or an application containing any materially false, incomplete, or

CWA

Subsidiary list:

administered by Pre-Paid Legal Services®, Inc.

FOB

GR#

Office Use Only

MODE

PLAN

FRAN

X

Applicant: I understand that the written contract sets forth the terms of my membership, includingany 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 fourteendays. If I have not received my contract within that time frame, I understand that it is myresponsibility 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

member information Print only

Today's Date

Month Day Year

This will be your member number.SSN #

LastName

- -

.

First

Apt./ Ste. #Street Address

Mailing Address

.

City

Last

State

Member's Date of Birth

Spouse

01/01/1966

.First .

Work Phone Ext.( ) -

Home Phone ( ) -

If you choose the bank draft option, your account will be drafted on or about this date each month.

Zip + 4

MI

MI

900000008

State of SaleTime of day _____________ CA

membership contract.

payment informationAuthorization for Electronic Transfers Drawn by and Payable for Premium: I hereby authorize Pre-Paid Legal

This authority is to remain in effect until Pre-Paid Legal Services®, Inc., or applicable Services®, Inc. or applicable subsidiary, to charge/draft my checking/savings account from the Financial Institutionlisted below.

each month on or about the effective date of your membership.

Select the payment method you prefer.Your credit card charge or your check is your receipt.

subsidiary, receives written notification from me revoking the authorization. Your account will be drafted

(Financial Institution)Name of Bank

Bank Address

CITY STATE ZIP

Monthly or Annual Bank Draft

Monthly or Annual Payment by Credit Card (Your account will be charged on or about the 15th, 20th, or 25th of the month)

I wish to pay by credit card until I revoke this authorization in writing.

Exp. Date: (Mo./Yr.)Card #:

Cardholder Signature:

I hereby authorize my employer _______________________________________ City _____________________ State_________ to deduct $ ___________ from myearnings for my Pre-Paid Legal Services®, Inc., or applicable subsidiary, membership.

Payroll Deduction Authorization (For employee benefit sales only, $10 enrollment waived.)

By signing this application I certify I am legally residing in the United States of America. I have received Primerica's privacy policy, "Your Privacy is Important to Us."

Signature of Applicant

DependentsDate of Birth

Date of Birth

Date of Birth

In Florida, any person who knowingly and with intent to injure, defraud, or deceive any insurer

misleading information concerning a material fact is guilty of a felony of the 3rd degree.

X

X

a.m.p.m.

Check One

Representative Solution Number WM251

Representative Name Michael Kan

Signature of RepresentativeRepresentative License Number (FL only)

Field Trainer Solution Number Field Trainer Name

Signature of Field Trainer XFor R

epre

sent

ativ

e U

se O

nly

Print name ____________________________ SSN ______________________

Date ____________ Applicant signature:X

Ohio Access to Justice, Inc.Legal Service Plans of Virginia, Inc.

Pre-Paid Legal Services®, Inc.

National Pre-Paid Legal Services of Mississippi, Inc.Pre-Paid Legal Services, Inc. of Florida

Pre-Paid Legal Services of Tennessee, Inc.Pre-Paid Legal Casualty™, Inc.

Acct. #

Checking Account

Institution Transit #Signature of Account Holder

(Attach check from account to be drafted.) (Attach account verification.)

Savings AccountX

Last / First / MI

Last / First / MI

Last / First / MI

BANK DRAFT OR CREDIT CARD

$$

$Total enclosed by check, money order, or charged to credit card

(If paying by credit card, I realize my first charge will include a one-time enrollment fee where applicable.)

Monthly/Annual draft/Charge amount

One-time entrollment fee

A $10 non-refundable fee is required for individual enrollments. Remit $10 enrollment fee plus first month's membership fee for processing.

applicationmembershipUNIVERSAL

Primerica Legal Protection ProgramRemit application to: Pre-Paid Legal Services®, Inc., and subsidiariesCorporate Offices: P.O. Box 145 • One Pre-Paid Way • Ada, OK 74821-0145

(see list)

MasterCard Visa Discover AMEX

Annual Direct BillI wish to pay annually by check.Checks should be made payable to Pre-Paid Legal Services, Inc.

Amount enclosed: __________* Must include first year payment.

For internal use only by PPLSI. Our privacy policy is available upon request.

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PLPP.UNI • (4.04) © 2011 Primerica