CDL Legal / Dalys FORM

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Name*
First Last
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Phone
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Email*
Please Select One Of The Following*
- I am a CARRIER wanting more information.
- I am a DRIVER signing up for membership.
My DOT number:
I Work For:
Spouse's Name
First Last
My Address*
Street Address City State ZIP Code
CDL Number*
CDL State*
Last 4 Digits of SSN*
Date of Birth*
MM slash DD slash YYYY
Please Charge Me
- $35.09 / Monthly
- $97.49 / Quarterly
- $385.99 / Annually
Desired Start Date
MM slash DD slash YYYY
Type Of Card
- Visa
- Mastercard
- American Express
Card Number
Card Number
Card Billing Zip*
Expiration Month
Expiration Year
Security Code (MC/Visa)*
Security Code (Amex)*
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.