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Section 1 - Applicant Information
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Section 2 - Type of Plan
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Select a Plan Type

Please select either an Individual of Family Plan membership. An individual is only you, a family is you, a spouse, children up to the age of 18 (24 if a full/part time student) and dependent seniors.

Section 3 - Plan Version & Schedule
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Please select a plan version (Complete or Basic) and the payment schedule of your choice.

Individual Plan Version & Schedule Options
Family Plan Version & Schedule Options
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Section 4 - Payment Options

You may choose to be billed directly based on the installment you chose or you may have the fee automatically charged each installment to a credit/debit card.

(direct billing not available for monthly installment)

Please select one
Is the name and address on the card the same as your address above?
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Section 5 - Agree to Terms and Submit Application

Please read and accept each of the terms below by clicking the check box to the left of each then e-sign the application and click on "Submit".

I agree that once received, I will read my membership agreement.

I understand that an American Legal Services, Inc. membership is an annual agreement even if you choose an installment option.

I understand that if I am paying by Credit/Debit card that my card will automatically be charged each installment. and if I choose to be billed directly each installment, I that I will receive a bill in the mail each installment period. I further understand that either billing method will remain in place until I properly cancel my account as described in my membership agreement.

All of the information that I have provided on this application is correct to the best of my knowledge.

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Add your family information here. If you have more dependents that there are spaces, simply select

 

"Additional Dependents Apply"

 

Dependents should be listed

by age.

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A monthly billing schedule requires automatic credit/debit card payments. Direct billing is not available for the monthly billing schedule. Also, there is a 90-day waiting period before benefits are active. Benefits are active as soon as your initial payment is received with any other billing schedule.

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Direct Billing means you will receive a bill in the mail each installment period.

 

Credit/Debit means that your card will automatically be charged each installment period.

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You can simulate your signature either with your finger or if you are using a PC,

you can use your mouse

This application is for the 2024
NEARI Open Enrollment
You can choose to enroll here by completing this application 
or by calling

401.944.7400 

Either way the process only takes
a couple of minutes.

January 2nd  - January 31st

IMPORTANT !   -   See Note -->
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