ATPE

If you do not know your plan details, please contact Texas Legal for assistance with your request.

Group Policy Information: If you select the family coverage option list all dependents/family members you wish to include on the policy. Eligible Dependents means (1) Participant’s spouse; and all of Participant’s children, including step-children, legally adopted children, children for which Participant is the legal guardian, any of which are under twenty- six (26) years of age; or (2) the definition of eligible dependent provided by the Master Policyholder for all other benefits offered by the Master Policyholder provided that said definition is more broad than (1) above and Master Policyholder provides a copy of same to Texas Legal. Notwithstanding the forgoing, an Eligible Dependent child may not be older than 26.

Please note that dependent changes may result in a premium adjustment.

By signature of this application, you hereby authorize Texas Legal to charge/draft your checking/savings account from the financial institute listed. This authority is to remain in effect until Texas Legal receives written notification from you revoking the authorization. This account will be drafted at the beginning of each month. Payment is due on the 1st of each month. Your account may not reflect the debit until the 2nd and later depending on the bank or credit union transactions or guidelines. Each financial institution establishes its own guidelines.