Quote Form Test 2 | Cluett Insurance

Name *

Phone *

Email *

Have you been continuously insured for the past 10 years?

Yes

Any cancellations for non-payment in the past 5 years?

Yes

Any at fault or not at fault claims in the past 6 years?

Yes

Any convictions in the past 3 years?

Yes

Are you looking for both property and auto insurance quotes?

Yes

As your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation/application, any policy we issue and subsequent renewals or changes, we may collect, use, and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies.

Do you, and on behalf of others listed, authorize use to collect, use and disclose to appropriate third parties, including your broker, this information solely relating to your personal property policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settle claims, analyze business results and detect and prevent fraud?

Do you agree with the following consent statement?

Yes

If you are human, leave this field blank.