CDL Legal / Payroll Deduction Confirm

Name
First Last
Phone
Email
Member Information
Street Address City State ZIP Code
CDL Number
CDL State
Date of Birth
Date Format: MM slash DD slash YYYY
Last 4 Digits of SSN
Acknowledgement*
- I am electing to participate in CDL Legal and authorize my company to deduct from my payroll/settlement the member fees as set above to be paid to CDL Legal. CDL Legal may share with participating carrier information about member claims as part of company safety reviews. Coverage goes into effect after the first payroll/settlement deduction by your company. Plan fees may change with 30 days written notice from CDL Legal. By checking the box, I am agreeing to the CDL Legal terms and conditions. Please refer to our website. I understand that I may cancel my plan benefits at any time.
Carrier Name
Carrier SF ID