DEDUCTION AUTHORIZATION
 For legal expense insurance

 

Last Name: __________________  First Name: ______________________  MI__

 
SS# ___________________________


Employee Payroll Account # ______________________

 

  
In connection with my application for benefits through Signature Legal Care, I hereby authorize my Employer as my agent to deduct the cost to me for such contract as shown below, and as may be hereafter modified or adjusted, from my wages or salary. 


 I understand that coverage cannot be cancelled until the next Open Enrollment.

 

PREMIUM TO BE DEDUCTED:

  

[ ] Individual ($2.68 per pay period)
[ ] Family ($3.58 per pay period) 
[ ] Cancel Coverage
[ ] New Hire
[ ] Open Enrollment

 

 


Signature __________________________________
Date: ______________

 

 

 

revised 8/2006