Student Legal Enrollment Form

Gulf Atlantic Legal Defense
Insurance Inc.

2549 Barrington Circle
Tallahassee, FL 32308
Tel.: (850) 422-8460
Toll Free: (800) 488-4732
Fax: (850) 385-1657

Click Here to confirm you have read and agree to the below disclosures and certification.

  1. This enrollment form is an application for a prepaid legal insurance policy issued by Gulf Atlantic Legal Defense Insurance, Inc. ("Gulf Atlantic"). The policy provides prepaid legal services for University and College students. The policy does not cover You for settlements, judgments, awards or other forms of damages for which you may become liable. If you have provided payment with this enrollment form, coverage will begin on the day our underwriters approve coverage. If you have not provided payment with this enrollment form, coverage will begin on the day after the later of the date we notify you that you have been approved or the date we receive your payment.
  2. Any person who knowingly and with intent to injure, defraud or deceive any insurer files any statement of claim or an application containing any false, incomplete or misleading information is guilty of the third degree.
  3. If transmitted to Gulf Atlantic by facsimile, e-mail or other electronic means, you agree that the facsimile copy of this application and your digital signature shall be, and shall have the same effect for all purposes, as the original.


I hereby certify that the above statements, representations and responses are true, complete and correct, and I understand and agree that Gulf Atlantic will rely on such statements, representations and responses in making a decision as to whether to issue a policy to me.