Application and Salary Deduction Authorization Form
for Legal Club of America

How to Enroll
Simply complete the enrollment form below. If you need assistance or have any questions, please call the CSEA Member Benefits Office at: (916) 326-4283 or for California residents only (800) 952-5283.

Upon completion of the enrollment form, you may contact Legal Club of America® to use the plan immediately. You may call the customer service toll-free number at (800) 305-6816 to receive an attorney assignment right away.

Member Information:
California State Employees Association (CSEA)
First Name:

Last Name:
Middle Initial:
Date of Birth:
SSN:
   
Home Address:
City:
State:
Zip Code:
   
Home Phone #:
Work Phone #:
Email Address:

 

Salary Deduction Information:

YES, I want to take advantage of this special offer of membership in the Legal Club of America® discount legal services program and receive access to all the services and benefits outlined. I understand that the fees and charges sought by the participating plan attorneys may only change if posted to the Legal Club Web site. Legal Club of America® and its agents are not party to any confidential attorney/client relationship that I may establish. I understand that this plan is not an insurance coverage. I understand that I may not use the plan and any of its attorneys to adversely affect my employer or plan sponsor. Upon enrollment, I have thirty (30) days to cancel my membership. The annual membership shall automatically renew unless terminated thirty (30) days prior to the expiration date of the term. I also understand my Legal Club of America® membership will continue, as long as payments are received, unless terminated in writing with proper advance notice.

I am an active employed member of CSEA
I am an retired member of CSEA

Please choose only ONE payment method:
All for only $12 per month!
 

(1) Payroll Deduction
 
I hereby enroll for a legal plan offered through Legal Club of America®. I am either an active employed member of CSEA or I am a retired member of CSEA. I understand that if I am an actively employed member of CSEA, the State of California will deduct the premium for Legal Club of America® from my salary or wages. I understand that if I am a retired member of CSEA, Public Employees Retirement System will deduct the premium for Legal Club of America® from my retirement allowance.

   

(2) Checking/Savings Account Deduction:
 
Account Type (Select One):
       Checking
       Savings
 

Bank Name:
Name on Account:
Routing Number:
Between "/:/:" on your check
Account Number:
 
I want the premium to be taken from my account:
      on the 1st of each month
      on the 15th of each month
   

(3) Credit Card Payment Information:
 
Credit Card (Select One):
      Visa
      Master Card
      American Express
      Discover
 

Credit Card Number:
Expiration Date:
Name on Card: