Legal Insurance for ASQ Members As an ASQ member, you can subscribe to legal protection in matters of ethics and discipline. First Name Last Name Membership number of your professional association Address City Postal Code Email Phone Number Have you ever had legal insurance? Yes No If yes, what is your retroactive date? (optional) Have you personally been a party to a disciplinary investigation? Yes No Have you personally received verbal or written notice that you will be sued? Yes No Are you aware of any facts that could lead to legal action against you? Yes No Are you aware of any circumstances that may give rise to a claim for payment at the end of the policy? Yes No Have you ever been served with a lawsuit? Yes No I certify that I have read the above information and that my answers are true. Please be advised that any act prior to this date will not be covered by this policy. A waiting period of 60 days following the issuance of this policy will apply to any new claim. I agree to proceed with the purchase of the online legal insurance without the assistance of a certified insurance broker. Checking "Yes" to this statement constitutes my acceptance and confirms my intention to purchase the insurance policy online for $150 (+ $20 professional fee). Yes No Once the form is submitted, you will receive the documentation related to your insurance policy by email in the next few days, provided that you meet the underwriting criteria of the insurer. For additional information, please contact a broker at 1-855-587-7437 #Ext: 13026.