Secure LTD Enrollment Form – Policy # 24033

CONSENT TO USE ELECTRONIC RECORDS AND ELECTRONIC SIGNATURE
By submitting this form you hereby agree to conduct this transaction by electronic means and in an electronic format. By checking the "Yes - I want to participate" box above and entering your Social Security Number wherever this language appears on this site is your "electronic signature." You agree that it is your lawful, original signature for the purpose of authenticating the validity of documents agreed to by you. For your protection, all of your account information is placed on a secure portion of this Site. Life Solutions uses Secure Sockets Layer (SSL) technology certified by a recognized third party certificate of authority.

You may contact Life Solutions, P.A. at any time to:

  1. Withdraw this consent to conduct a transaction by electronic means; or
  2. Request a paper copy of enrollment form transaction; or
  3. Update your account information, including your e-mail address.