ELECTRONIC DELIVERY OF INSURANCE POLICY

DISCLOSURE STATEMENT

  1. You have the right to request that a paper copy of any insurance policy and endorsements or other changes to it obtained by you through this agency be given to you instead of electronically delivered.
  1. If you sign the attached Consent form, it will apply to any insurance policies and endorsements or other changes to them that you may obtain through this agency.
  1. You have the right to withdraw your consent to the electronic delivery of any such insurance policies and endorsements or other changes to them at any time by sending an e-mail to the address shown on the attached Consent form. The withdrawal of your consent will only be effective for the delivery of such documents that occurs more than _____ days after the date notice of the withdrawal of your consent is received by this agency. [Optional – In order for the withdrawal of your consent to be effective, you must pay this agency a fee of $______. ]
  1. If you want to change the e-mail address to which the electronic delivery of any such insurance policies and endorsements or other changes to them is to be made, please send an e-mail containing the new e-mail address to which the delivery of such documents is to be made to ______. Any such change in the e-mail address to which the delivery of such documents is to be made will only be effective for the delivery of such documents that occurs more than ______days after the date notice of the new e-mail address is received by this agency.
  1. If you consent to the electronic delivery by this agency of any such insurance policies and endorsements or other changes to them, you may request that a paper copy of any such documents also be given to you. Any such request must be made to ______. [Optional – A fee of $______must be paid by you before a paper copy of any such documents will be given to you.]
  1. In order for you to be able to view and retain any insurance policies and endorsements or other changes to them that are delivered to you electronically by this agency, you must have (a) a computer, iPad, or other electronic device that has access to the internet; (b) a valid e-mail address; (c) an operational program installed on your computer, iPad, or other electronic device capable of receiving e-mail; (d) an operational program installed on your computer, iPad, or other electronic device that will permit you to view a document in the following format: ______; and (e) a hard drive, thumb drive, or other device included within or attached to your computer, iPad, or other electronic device to which a document in the above format may be permanently downloaded.

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