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Account information

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Confirm e-mail address: *

Please re-type your e-mail address to confirm it is accurate.

Account Information

Your First Name: *

Your Last Name: *

Address Line 1: *

Address Line 2:

City: *

State/Province: *

Zip / Postal Code: *

Home Phone:

Cell Phone:

Date of Birth:

Gender: *

Accounts I have with this agency:

Personal Insurance

Business Insurance

Insurance Info - Business Insurance

Are you the owner or manager of this business?:

This question is required for Commercial Lines customers only; if you are not the owner or manager of this business, do you have the permission of the owner/manager to submit information regarding their insurance program? If the answer is "No", please close this form and have the owner or manager sign up themselves.

Business Name:

You only need to enter this if you have Commercial Lines coverage with this agency.

Business Phone:

Terms and Conditions of Use

Terms & Conditions:

I understand that any insurance terms and definitions are meant for general informational purposes and not meant as specific advice or recommendations. For detailed information, it is my responsibility to contact [AGENCY NAME].

I understand that no coverage will be assumed bound or covered until I have received written or verbal confirmation from a licensed agent of [AGENCY NAME].

I understand that [AGENCY NAME] will receive documentation of service requests, requests for information or declination for additional information, which may become part of my customer file.

I understand that [AGENCY NAME] will process service requests based on information provided through this site and that I will receive confirmation of all changes to my coverage. I authorize all such changes, and assume the responsibility of notifying [AGENCY NAME] in the event of errors or misunderstandings.
1. Guarantee of privacy of client information and all privacy language.

2. [AGENCY NAME] will handle service requests in good faith based on registration information. All service requests will be confirmed to the client and they must contact [AGENCY NAME] in case of error.

3. Client is responsible for updating email address and other information in the event of change.

4. Insurance terms, descriptions of coverage and other insurance information is not meant to be complete, and the client should either contact [AGENCY NAME] or read their policy for complete information.

5. All insurance and non-insurance information is for general purposes and may not be up-to-date or complete. [AGENCY NAME] is not responsible for information in sites linked.

6. No changes will be considered to be bound until the client has received confirmation from [AGENCY NAME].

7. Client is solely responsible for all security issues surrounding use of their private password. [AGENCY NAME] cannot access password therefore client acknowledges and accepts full responsibility if password is given to another party.

Privacy Statement

[AGENCY NAME] has always been committed to ensuring the confidentiality of the information it receives. Recently, Congress enacted the Financial Services Modernization Act, which requires that certain companies, including insurance agencies, inform their customers how personal information is collected or disclosed. [AGENCY NAME] maintains physical and electronic safeguards to protect the information we acquire, including restricting access about you to employees who need to know that information to provide you with products or to provide you with benefits or services we feel would be useful to our clients. We periodically review and test our systems to assess the strength of our security precautions.

The following notice is the [AGENCY NAME] Privacy Policy.

Our Privacy Policies and Practices
We do not sell client information for any reason whatsoever. We may collect non-public personal information about you from the following sources:
- information we receive from you on application or other forms;
- information about your transactions with us; and
- information we receive from a consumer reporting agency

We will not disclose non-public personal information about you to others unless the disclosure is necessary to conduct our business and is permitted by law. We thank you for the confidence you have placed in us and are committed to protecting your privacy and confidentiality.

Upon acceptance thereof, I agree to be bound by these Terms & Conditions

If I at any point in time disagree with any portion of the Terms & Conditions I will immediately discontinue use of this website

Accept Terms & Conditions of Use

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