FW-Change

Upload copy of new ID or Marriage Certificate

If you are changing your name, you will need to provide a digital copy of your marriage certificate or new legal identification. You may upload jpg, png or pdf files. You may upload a maximum of three files. Each file must be under 2MB.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 6 MB.

Update Address or Phone Information

Add or Remove Dependents

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, and Participant’s children over age twenty-six (26) who suffer from a permanent and total physical or mental disability and where the Participant’s or Participant’s spouse has provided more than one half of the disabled child’s support in that Plan year; 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 unless the child has a disability.

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

	Select Monthly/Annual	Preferred Monthly/Annual
Single Coverage	$18/198	$28/309
Family Coverage	$28/309	$45/495

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

	Monthly	Annual
Single Coverage	$26.00	$280.00
Family Coverage	$40.00	$435.00

Do you wish to add or remove dependents?*

How many dependents do you wish to add?*

If you wish to add more than four dependents, please contact us directly at 1-800-252-9346.

How many dependents do you wish to remove?*

If you wish to remove more than four dependents, please contact us at 1-800-252-9346.

Add, Update or Change Payment Type and/or Frequency

Please note that selecting single will cause any covered dependents to be terminated.

Total Monthly Charge

Payment Method*

NOTICE: Returned Bank Drafts/Checks/Credit Card Payments Incur a $25 Fee.

Will the bank draft come from a Checking or Savings account?*

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.

9 Digit Bank Routing Number*

Bank Account Number*

Cancel Coverage

Cancellations are not effective until the last date of the month if the request is received by the 25th of the month. If the cancellation request is received between the 26th and the 31st of the month, the cancellation will not be effective until the last date of the following month (i.e. a cancellation request received on May 27th will not be effective until June 30th).

Stay Current.

Update Policyholder Information

Update Address or Phone Information

Add or Remove Dependents

Add, Update or Change Payment Type and/or Frequency

Cancel Coverage

Signature and Terms