Index For office use only Date received:__________ Certificate Ref:__________ Payment Ref:_________ Initials:_____

The Legal Defence Union

Membership Application Form

1. I/We wish to apply to be registered as a Member of The Legal Defence Union Limited.

Member Name:

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Postal Address:

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Telephone

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 Fax

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Email

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Contact Name:

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 Position

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2. I/We wish to apply as (please tick)

Individual Member

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Employed Member

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Corporate Member

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3. For Corporate Membership, please advise the number of:

i) Partners:

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 ii) Associates:

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iii) Consultants:

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 iv) Employed Solicitors

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Please include any retired partners for whom cover is required.

4. Are you, after enquiry, aware of any circumstances that

a) may give rise to a claim being made under the Legal Defence Union Legal Expenses scheme?

Yes . No .

b) would have given rise to a claim under the scheme had cover been in place at the time of the incident (including incidents that occurred whilst any Partner was working for another firm)

Yes . No .

If the answer to a) or b) is 'Yes', please give details below

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Please continue on separate sheet if required. Please tick if separate sheet attached.

5. Do you require SLAB Protection to be added to your subscription?

Yes . No .

6. Do you require Employment Cover to be added to your subscription?

Yes . No .

7. Method of Payment

By cheque made payable to "Legal Defence Union Ltd" (please attach)

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By Direct Debit (please complete attached mandate)

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8. Declaration for Insurance Purposes

I/We declare that the above statements made by me/us or on my/our behalf are to the best of my/our knowledge and belief true and complete and I/we agree that this proposal will form part of the contract between the Insurer and myself/ourselves.

Signature __________________

Date __________________

Paying your subscription

Please return the completed form with your remittance to:

The Legal Defence Union Ltd

Athas House

Inchbare

By Edzell

DD9 7QL

Tel: 01356-648480

You may alternatively wish to pay by Direct Debit Mandate over a period of six months from May to October at no additional charge.