ࡱ>  @ bjbj{{ l|rRLRLRL8LM$\k&FOP(QQQ2TbUhVljjjjjjj$mRoji}]S^.T}]}]jQQk___}]"RQ8Qj_}]j__d"_Q:O uRL]:_S`4 ,k0\k_Xp]Xp_Xp_W"Y_4Z[mVjW$WjjD1.7$_".7 STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS PREPAID LEGAL SERVICES PLAN APPLICATION FOR NEW OR RENEWAL CERTIFICATE OF REGISTRATION S.C. Code Ann. 37-16-204  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov 803-734-4236/800-922-1594 Name of Prepaid Legal Services Plan: FORMTEXT       Street Address: FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Mailing Address: (if different from above) FORMTEXT       Telephone Number: FORMTEXT       Fax Number: FORMTEXT       President of Prepaid Legal Services Plan: FORMTEXT      Also Enclosed:Filing Fee  FORMCHECKBOX ($800.00)Audited Financial Statement FORMCHECKBOX Bond FORMCHECKBOX ($50,000.00) Company:  FORMTEXT       Number:  FORMTEXT      Original or certified, true copy of Certificate of Existence if South Carolina corporation. FORMCHECKBOX On initial application the original or certified, true copy of Certificate of Authority to do Business in South Carolina if non-South Carolina corporation. FORMCHECKBOX orFor renewals an out-of-state corporation needs to submit A current Good Standing Certificate from the S.C. Secretary of States Office.  FORMCHECKBOX  To the Department of Consumer Affairs Columbia, SC Part I On behalf of ________________________________, (hereinafter Plan) of _________________________, (Name of prepaid legal services plan) (City) ___________________ a prepaid legal services plan created under the laws of the State of ____________________, (State) (State) I ________________________, hereby apply for a Certificate of Registration pursuant to Section 37-16-10 et seq. of (Authorized Representative) the South Carolina Code of Laws authorizing and empowering the above named prepaid legal services plan to operate in the State of South Carolina under such Certificate until it is surrender, suspended, revoked or terminated by the South Carolina Department of Consumer Affairs (Department). Part II I, _____________________________, of ________________________________, agree, pledge and certify that the (Authorized Representative) (Name of Plan) Plan will operate in accordance with and obey and abide by all applicable laws of the State of Carolina, including the following South Carolina Consumer Protection Code and the provisions specified by Section 37-16-10 et seq. 1. Accompanying this application to the South Carolina Department of Consumer Affairs (hereinafter Department) is a bond or letter of credit (check one) in the amount of $50,000, made in favor of the State of South Carolina, which will remain in force as long as the Plan conducts business in South Carolina. 2. Any person to be appointed by the Plan for the purpose of direct selling or direct in-person or electronic solicitation of the general public or segments of the general public on behalf of the applicant will complete an appointment form prescribed by the Department. Said appointment form will be transmitted to the Department, accompanied by payment of a $40.00 annual fee, prior to commencement of any activity described in this paragraph by the person appointed. The appointment, with annual payment of $40.00, will be renewed each year no later than October 1. 3. Plan will file with the Department, no later than March 1 of each year, on a form prescribed by the Department, an updated current renewal registration statement. 4. Plan will pay an annual registration fee of eight hundred dollars in connection with its annual registration. 5. Plan will file with the Department for approval any contracts offering prepaid legal services prior to their being offered to the general public or a segment of the general public. Part III 1. Has play had any professional, vocational or business license denied, suspended, revoked or restricted by any regulatory authority in this or any other state or been withdrawn or surrendered to avoid disciplinary action, or has Plan been subject of any monetary penalty or fine by such authority? Yes No (If yes, attach explanation) 2. Has Plan had any judgment rendered against it in any court of any jurisdiction of the United States for its activities relating to the transaction of business as a prepaid legal services plan? Yes No (If yes, attach explanation) 3. Has Plan been declared insolvent or discharged from bankruptcy within the last ten (10) years? Yes No (If yes, attach explanation) 4. Have any Plans officers or directors been indicted for or convicted in a criminal proceeding (excluding minor traffic violations) within the past ten (10) years? Yes No (If yes, attach explanation) Part IVFinancial InformationPlans financial condition as of calendar year ending within one year prior to date of renewal.Total Assets$ FORMTEXT      Total Liabilities$ FORMTEXT      Stockholders Equity$ FORMTEXT      Total amount collected from members nationwide for previous calendar year$ FORMTEXT      Total amount collected fromMembers in South Carolina only$ FORMTEXT      FOR SCDCA USEFiling Fee FORMCHECKBOX ApprovedAudited Financial Statement FORMCHECKBOX Bond FORMCHECKBOX Certificate of Authority/Existence FORMCHECKB9:UWXY̹r_M;,hw5CJOJQJ]aJ"hH^:hw5CJOJQJ]aJ"hH^:hw5CJOJQJ\aJ%hH^:hw5>*CJOJQJ\aJ9jh\jh\j5>*CJOJQJU\aJmHnHu(jh\jh\jCJUaJmHnHu)h\jh\jB*CJOJQJ^JaJph%h\jhwB*CJOJQJaJphhhwCJOJQJaJhwCJOJQJaJ0jhhwCJOJQJUaJmHnHu9W  3   0*L0*L0* 0* 0*V0*V0*V0*00*0*SkdE$$Ifl0^*> t644 la $Ifgdn $Ifgd,gdw %d O gdwx  3 4 > ? 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h!eh!eCJOJQJ^JaJh!eCJOJQJ^JaJ#h!eh!e5CJOJQJ^JaJh!eh!eCJOJQJ^JaJ hL h!eCJOJQJ^JaJ/j3hZvhZvCJOJQJU^JaJU/j82hZvhZvCJOJQJU^JaJ#jhCJOJQJU^JaJ hL hCJOJQJ^JaJhCJOJQJ^JaJ#### _VaVA JV^J J $$Ifa$gd $Ifgd,kd2$$Iflֈ6$*9 6v  t644 laOX Date CertificationIt is hereby certified that the prepaid legal services plan making this application is organized under the laws of the State of ____________________, and has complied with the requirements of Section 37-16-10 et seq., S.C. Code Ann. relating to such plan. Finally, the undersigned swears or affirms under oath that he/she executed this application dated _________ , 20 __, for and on behalf of ____________________, that he/she is authorized to execute and file this application, that he/she has read and fully understands the requirements of 37-16-10 et seq., S.C. Code Ann. relating to such plan, and that the information contained in this application is true and accurate to the best of his/her knowledge. Signature of Applicant (or authorized Representative if Plan is a corporationPositionSubscribed and sworn to before methis ___ day of _________, 20 ___Notary Public for:My appointment expires: Prepaid Legal Application for New or Renewal Certificate of Registration Revised 02/08 Page  PAGE 4 of  NUMPAGES 4 Mailing Address P.O. 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