Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTax ID type *Social Security number (SSN)Individual Tax ID number (ITIN)Social Security number (SSN) *⛊ We need to ask for your SSN to verify your information. We'll keep your data secure. Phone *Email *Date of Birth *Type of residence *OwnRentOtherTotal gross annual income ($) *Employment status *EmployedSelf-employedUnemployedOtherDebtGuard Chosen Plan *Basic Shield $99 / MonthlyPlus Shield $179 / MonthlyPro Shield $259 / MonthlyElite Shield $329 / MonthlyMax Shield $399 / MonthlyVerification Upload * Click or drag files to this area to upload. You can upload up to 5 files. Upload your State ID / Driver's License (front and back) securely for verification with DebtGuard Name gross Electronic DebtGuard Application Agreement DebtGuard Application Agreement Certification and Agreement: I certify that I have read and agree to all pricing, terms, conditions, authorizations, and disclosures provided with this application for DebtGuard services, offered by LEVY'S CAPITAL GROUP LLC. I confirm that all information provided is true and correct. Plan Activation and Payments: I understand that my DebtGuard protection plan will be activated within the timeframe specified in my agreement, following the successful processing of my initial payment. Monthly payments must be maintained to keep the protection active. For any payment issues or modifications to my payment plan, I can contact LEVY'S CAPITAL GROUP LLC customer service using the information provided in my welcome kit. Account Responsibility: I will be responsible for all obligations under this account as specified in the DebtGuard service agreement. All correspondence, including account statements and notifications, will be sent to the name and address on file for the account holder. DebtGuard will provide account information to credit reporting agencies, which could impact my credit score. Eligibility: This product is not available to individuals who have received a cancellation refund from a DebtGuard plan within the last 48 months. Changes to Terms: I understand that the terms of my account, including fees and conditions, are subject to change. Any changes will be made in accordance with the DebtGuard Account Agreement and will be communicated to me in accordance with applicable law. Contact Information for Inquiries: If any issues arise or if I need to make changes to my account, I can contact LEVY'S CAPITAL GROUP LLC at 1-800-775-9711. Social Security Number Verification: I authorize the Social Security Administration (SSA) to verify and disclose to DebtGuard through Early Warning Services, LLC, their service provider for the purpose of this transaction, whether the name, Social Security Number (SSN), and date of birth I have submitted match information in SSA records. My consent is for a one-time validation within the next 90 days. Electronic Signature *I've read and agree to the above.Submit