"Initial Registration Statement Form for Prepaid Legal Services Plan" - North Carolina

Initial Registration Statement Form for Prepaid Legal Services Plan is a legal document that was released by the North Carolina State Bar - a government authority operating within North Carolina.

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INITIAL REGISTRATION STATEMENT FORM FOR
PREPAID LEGAL SERVICES PLAN
Any person or entity seeking to operate a prepaid legal services plan shall register the plan with
the North Carolina State Bar on the initial registration statement form provided by the State Bar. Each
plan must be registered prior to its operation in North Carolina.
The plan owner shall complete this form and file it with the secretary of the State Bar. The
plan owner must provide complete responses to each of the following items. The plan will not be
registered if any item is left incomplete.
1. Name of Plan:
_______________________________________________
a. Owner of Plan
i. Name: _______________________________________________
ii. Title: _______________________________________________
2. Principal North Carolina Address for Plan
a. Address:
_______________________________________________
b. City:
_______________________________________________
c. State:
_______________________________________________
d. Zip Code:
_______________________________________________
3. Contact Information for Plan Representative
a. Name:
_______________________________________________
b. Address:
_______________________________________________
c. City:
_______________________________________________
d. State:
_______________________________________________
e. Zip Code:
_______________________________________________
f. Telephone Number:
_________________________________________
g. Email Address: ______________________________________________
4. Is the plan offered by a person or entity not authorized to engage in the practice of law?
☐ Yes
☐ No
5. Does the plan, in exchange for any valuable consideration, offer to arrange the provision of
specified legal services that are paid for in advance of any immediate need for the specified
legal service (“covered services”)?
☐ No
☐ Yes
6. Are the legal services the plan offers to arrange provided by North Carolina licensed attorneys
who are not employees, directors, or owners of the plan?
☐ Yes
☐ No
Initial Registration Statement Form
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Page 1 of 2
INITIAL REGISTRATION STATEMENT FORM FOR
PREPAID LEGAL SERVICES PLAN
Any person or entity seeking to operate a prepaid legal services plan shall register the plan with
the North Carolina State Bar on the initial registration statement form provided by the State Bar. Each
plan must be registered prior to its operation in North Carolina.
The plan owner shall complete this form and file it with the secretary of the State Bar. The
plan owner must provide complete responses to each of the following items. The plan will not be
registered if any item is left incomplete.
1. Name of Plan:
_______________________________________________
a. Owner of Plan
i. Name: _______________________________________________
ii. Title: _______________________________________________
2. Principal North Carolina Address for Plan
a. Address:
_______________________________________________
b. City:
_______________________________________________
c. State:
_______________________________________________
d. Zip Code:
_______________________________________________
3. Contact Information for Plan Representative
a. Name:
_______________________________________________
b. Address:
_______________________________________________
c. City:
_______________________________________________
d. State:
_______________________________________________
e. Zip Code:
_______________________________________________
f. Telephone Number:
_________________________________________
g. Email Address: ______________________________________________
4. Is the plan offered by a person or entity not authorized to engage in the practice of law?
☐ Yes
☐ No
5. Does the plan, in exchange for any valuable consideration, offer to arrange the provision of
specified legal services that are paid for in advance of any immediate need for the specified
legal service (“covered services”)?
☐ No
☐ Yes
6. Are the legal services the plan offers to arrange provided by North Carolina licensed attorneys
who are not employees, directors, or owners of the plan?
☐ Yes
☐ No
Initial Registration Statement Form
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Page 2 of 2
a. Attach a list of the names, addresses, bar numbers, and telephone numbers of all North
Carolina licensed attorneys who have agreed to participate in the plan. This list should
be alphabetized by attorney last name.
7. Do the covered services the plan offers to arrange extend beyond the sale of an identified,
limited legal service, such as drafting a will, for a fixed, one-time fee?
☐ Yes
☐ No
8. Has the plan owner signing below read and gained an understanding of the administrative rules
applicable to prepaid legal services plans as adopted by the State Bar Council?
☐ No
☐ Yes
9. Does the plan owner signing below agree to comply with the administrative rules applicable to
prepaid legal services plans as adopted by the State Bar Council and accept responsibility for
the plan’s compliance with those administrative rules?
☐ No
☐ Yes
10. Has the plan owner signing below read and gained an understanding of the law governing the
unauthorized practice of law as set out in N.C. Gen. Stat. § 84-2.1, 4, and 5?
☐ Yes
☐ No
11. Is a check for the initial registration fee made payable to the State Bar enclosed with this
statement?
☐ No
☐ Yes
12. After reading the foregoing form and the list of all North Carolina licensed attorneys who have
agreed to participate in the plan in its entirety, does the plan owner signing below certify that
all statements made in this form and the list of all North Carolina licensed attorneys who have
agreed to participate in the plan are true and correct to the best of his or her knowledge?
☐ Yes
☐ No
________________
__________________________________
Date
Signature of Plan Owner or Sponsor
__________________________________
Typed Name of Plan Owner or Sponsor
Initial Registration Statement Form
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