AUTHORIZATION TO SEND TEXT MESSAGES

By signing this form, I authorize <<Agncy_Name:PC>> to send text messages to my cell phone to convey information regarding insurance. I understand that standard text messaging rates will apply to any messages received from <<Agncy_Name:PC>>.

I also understand that I or <<Agncy_Name:PC>> may revoke this permission in writing at any time. I agree not to hold <<Agncy_Name:PC>> liable for any electronic messaging charges or fees generated by this service. I further agree that in the event my cell phone number and or cell provider changes I will inform <<Agncy_Name:PC>>.

Name:______________________________________________

<<Cli_NamedInsuredsAll>>

E-Mail Address :<<Cli_PrimaryEmail>>

Cell Phone #: <<Cli_CellPh>>

Cell Phone Provider:___________________________________

(Example: AT&T, T-Mobile, Sprint, etc.)

X_________________________________________________

(Signature)

Sincerely,

<<User Name>>
<<Agncy_Name>>
<<Agncy_Address>>, <<Agncy_City>>, <<Agncy_State>>  <<Agncy_Zip>>
Phone:<<Agncy_Phone>>  |  Fax: <<Agncy_Fax>>