Legal Advisory Plan Application

I am applying for membership in the Massachusetts Medical Society(MMS) Legal Advisory Plan(LAP) for the next eligible enrollment period or renewing my plan coverage.I understand and agree that my contract for the LAP is contained in the
MMS Legal Advisory Plan application and contract information. I have read the information and understand the plan and the extent of the coverage in it.I confirm that I am a member of the Massachusetts Medical Society.

Application Information

* First Name

Middle Initial

* Last Name

* Mailing Address

* City

* State

* ZIP

* Email

* Telephone

* Telephone Type

Fax

Group Name

Member ID

I am applying as

new plan participant
renewal participant

By entering my name below, I certify that I am applying for membership in the MMS Legal Advisory Plan.

* First Name

* Last Name

* = REQUIRED FIELD

Pricing

	Number of physician members	Price per person
	Individual	$95
	5-19	$90
	20-30	$85
	30+	$85*
	*Plus a FREE, on-site seminar given by the Plan Counsel, Adler, Cohen, Harvey, Wakeman, and Guekguezian, LLP

Add More LAP Members

To enroll more LAP members from your group, click " Add Another Member".
To enroll 5 or more members, please call(800) 322-2303, ext. 7311 or email lap@mms.org.

Payment Information

Payment Total $

Additional Information

Please print this page for your records.

Payment Method

Name as Printed on Card

Card Number

Expiration Month/Year