By submitting
this form, you acknowledge the following: A credit report or
other investigative report about you may be request in connection
with this application for insurance. Any information which we
have or may obtain about you or other individuals listed as
policyholders on your policy will be treated confidentially.
However,
this information, as well a other personal or privileged information
subsequently collected, may, under certain circumstances, be
disclosed without prior authorization to third parties such
as to our affiliated companies for claims handling, servicing,
underwriting and insurance marketing. Personal information also
may be disclosed to affiliated and non-affiliated companies
for non-insurance marketing purposes, unless you write to us
at the address provided on this website
and direct us not to make such disclosure.
You have
the right to see personal information collected about you, and
you have the right to correct any information which may be wrong.
If you
are interested in obtaining a description of our information
practices, and your rights regarding information we collect,
ask your agent, or, if you have been issued a policy, please
write us at the address provided with your policy.
First
Name
Last Name
Address
Address
City
State
Zip
E-Mail
Phone Number
Fax Number:
Current
risk Manager / Management Firm:
General
description of business:
Current
risk issues:
Status
of risk management program(s):
Retrospective Rating Plan in place:
Any other
comments: