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LEOLegalInsurance.com Group Form

 

Please complete this online form & we will contact you.

Alternatively, please download & complete this PDF form
which can be emailed or faxed to the contacts on the form.

 

General Information
Group Name
Group Address
Group City
Group State
Group Zip
Contact Person Org Title
Contact Person First Name 
Contact Person Last Name
Contact Person Telephone
Contact Person Fax
Contact Person E-mail 
Number of Members
Will this be the first time
Legal Protection is offered?

Yes
No
Please explain: 
How is Legal Protection obtained
by your membership today?
List the top 3 priorities/features desired
in your new Legal Protection Plan. 		1
2
3
How will you help to promote
the program? 
Do you expect to be compensated
for your involvement? 		 No
Yes
Please explain: 
What coverages are you interested
in receiving a quote for? 		Administrative
Civil
Criminal
Moonlighting
Firearms
Choice of Counsel
Good Samaritan
Toll-Free Hotline
Accidental Death
Benevolent Fund

Information About Your Group

Product Lines offered
(check all that apply):

 

Life
Accident 
Disability 
Health

Other (describe):
How often do you communicate
with your member base?		 Weekly
Monthly
Quarterly
Other (describe):
What methods do you use?
(check all that apply)

E-mail
Letters  
Newsletters/Magazines   
Meetings (describe):   
Briefly explain the decision making
process in your group:

 

 

 

The best way to reach us is by email to info@firstresponderlegalinsurance.com. We also may be reached by telephone at 516-933-1800 or by fax to 516-933-7777.