Application For Enrolment In Pre-Paid Legal Advice

Please fill the simple application form below, then click the "Submit" button and you will be taken to the secure payment page with the agreement. A hard copy of the agreement will be made available for you to sign either by post or when you visit any of our offices. We will contact you as soon as your application and payment are received.

Last Name: 

First Name:

Middle Name:

Address: 

Phone (Home): 

Phone (Work): 

Cell Phone: 

Email: 

Period of Legal Advice Applied For:

  1 year ($299)

  2 years ($550 = $275 per year)

  3 years ($750 = $250 per year)