E-SIGN Terms and Consent for Electronic Records and Electronic Signatures

Please read this information carefully and print a copy and/or retain this information electronically for future reference.

Introduction. You are submitting a request to be contacted by ____________________ and its agents, service providers, assigns and successors, (“__________________,” “us” or “we”) to discuss your insurance needs and the products offered by _____________________. We need your consent (“E-Consent”) to using and accepting electronic signatures (“Electronic Signatures”) and electronic disclosures and consent (“Electronic Records”) that authorize us to contact you for that purpose. This form notifies you of your rights when receiving and signing Electronic Records.

Option for Paper or Non-Electronic Records. You may request any Electronic Records in paper by calling us at _____________________ or mailing us at _______________________. We will provide paper copies at no charge. ___________________________ will retain copies of the Electronic Records as applicable law requires.

Scope of Consent. This E-Consent applies only to your agreement to receive promotional and marketing calls and text messages from us.

Consenting to Do Business Electronically. Before you decide to do business electronically with __________________, you should consider whether you have the required hardware and software capabilities described below. If you do not have the hardware and software required to access and retain the Electronic Records, or if you do not agree to the use of Electronic Records and Electronic Signatures, you will not be able to receive these promotional or marketing calls or text messages from _______________________.

Hardware and Software Requirements. To access, electronically sign and retain the Electronic Records, you will need to use the following computer software and hardware: A PC or MAC compatible computer or other device capable of accessing the Internet and an Internet Browser software program that supports at least 128 bit encryption, such as Microsoft® Internet Explorer, Netscape ® or Mozilla Firefox®. If these requirements change while you are maintaining an active relationship with us, and the change creates a material risk that you may not be able to receive Electronic Records, we will notify you of these changes. You will need a printer or a long-term storage device, such as your computer’s disk drive, to retain a copy of the Electronic Records for future reference. Please save and print a copy of this E-Consent to confirm that you have the required hardware and software to conduct electronic transactions with us.

Withdrawing Consent. You are free to withdraw this E-Consent at any time and at no charge, but doing so will not apply to any Electronic Signature that you provide us before withdrawing this E-Consent. If at any time you wish to withdraw this E-Consent, you can do so by calling us at: ________________________________________.

Change to Your Contact Information. You should keep us informed of any change in your electronic address or mailing address. You may update such information by visiting this website and providing the updated information. You may also send us your written update by mail to our address above.

CONSENT. BY CLICKING THE CHECKBOX TO ACCEPT THE TERMS OF THIS CONSENT FOR ELECTRONIC RECORDS AND ELECTRONIC SIGNATURES, YOU ACKNOWLEDGE AND AGREE THAT: (1) YOU HAVE READ THIS INFORMATION ABOUT ELECTRONIC SIGNATURES AND ELECTRONIC RECORDS; (2) YOU CAN ACCESS THE ELECTRONIC RECORDS IN THE FORMATS DESIGNATED IN THIS E-CONSENT; AND (3). YOU CONSENT TO USING ELECTRONIC SIGNATURES AND ELECTRONIC RECORDS.

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