CDL Legal / PAM / Confirm

CDL Legal

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Carrier Account SFID

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Carrier Account Name

Name*

First Last

Phone*

Email*

Address

Street Address City State ZIP Code

Spouse's Name (if available)

First Last

CDL State*

CDL Number*

PAM Driver ID

Last 4 Digits of SSN

Date of Birth

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 by contacting the PAM Payroll Dept..