By clicking the “I Agree To Electronic Delivery” button below, you are providing consent to [name of agency] (“Agency”) to provide documents to you electronically on behalf of the agency, the insurance companies represented by the agency, and other third parties. All documents sent by Agency to you are subject to this Consent Form, including but not limited to, any and all disclosures, declarations, contracts, policy forms, certificates, and/or documents, information, requests, applications, communications, and/or notices required by federal law, except when applicable law requires notice by another means. You agree that electronic delivery of documents is sufficient to meet all reporting and/or notice requirements, except when applicable law requires notice by another means. You are not required to receive documents electronically. If you do not agree to this Consent Form, please click the “I Do Not Agree To Electronic Delivery” button below, and Agency will provide documents in accordance with applicable law.
Your agreement to accept documents electronically means that once Agency delivers a document to you, and if required, you click to accept the document, the terms contained in the document apply to you. Additionally, it means that Agency may not mail you copies of documents that are provided electronically. You must print or otherwise retain a copy of this consent form for your records.
When Agency delivers a document electronically, it will do so by making the document available to you through an online customer portal where documents are placed for you to view or by sending the document by e-mail. You should check your e-mail periodically to ensure timely receipt of any document delivered electronically. You agree to access the portal within 10 days of receiving notification that a document has been posted. A document will be considered delivered to you when: (1) the e-mailed document leaves Agency’s system (if e-mailed); or (2) the document is posted on the portal. To be clear, a document is not considered delivered based on when you review the document.
The receipt of documents electronically has security and privacy risks. E-mail and online security and privacy cannot be guaranteed, and e-mails can be intercepted without your permission. If you agree to this Consent Form, you acknowledge and agree to accept these and other risks of receiving documents electronically.
Before agreeing to receive documents electronically, you must determine whether you have the necessary hardware and software to access and retain documents electronically. To access documents, you will need an e-mail address, Adobe Acrobat Reader, and a personal computer or other personal device that is capable of accessing the internet. To retain documents, your access device must have the ability to download to your hard drive, or an external media storage device, or to print the documents, as well as embedded HTML files. If you are unable to access a document electronically, you are obligated to notify Agency immediately by phone at [agency’s phone number] or by e-mail to [agency’s e-mail address]. If, after you have consented to the terms and conditions of this Consent Form, a change in the hardware or software requirements needed to access or retain documents electronically creates a material risk that you will not be able to access or retain subsequent documents delivered electronically, upon request, Agency will provide you with a statement of the revised hardware and software requirements for access to, and retention of, the documents, and the right to withdraw your consent without imposition of any fees for such withdrawal, and without imposition of any condition or consequence that was not disclosed in this Consent Form.
You have the option to request that Agency provide you with paper copies of the documents Agency provides to you electronically. If you wish to obtain a paper copy of a document, you may send an e-mail request to [agency’s e-mail address] or a written request to [agency’s physical address]. You will not be charged for paper copies of a document. Moreover, even if you consent to receive documents electronically, Agency may choose, in its sole discretion, to send paper copies of documents to you even though the documents were made or could have been made available to you electronically. Such delivery will be provided to you at the most current mailing address on file.
You may withdraw your consent to receive documents electronically, at any time and without charge, by sending an e-mail request to [agency’s e-mail address] or a written request to [agency’s physical address]. Withdrawal of your consent shall not affect the legal effectiveness, validity, and/or enforceability of documents provided or made available to you electronically prior to implementation of your withdrawal of consent. Your withdrawal of consent shall be effective within ten (10) days after receipt by Agency of your withdrawal request. Thereafter, such delivery will be provided to you at the most current mailing address on file.
You are the only individual authorized to access your documents from Agency electronically. You shall not share or disclose your password or other secure method to access documents delivered electronically. You shall take all reasonable measures to protect your access devices to prevent unauthorized access to documents delivered electronically.
You agree to notify Agency promptly of any changes to your mailing address, e-mail address, or other information. Notification may be by e-mail to [agency’s e-mail address], in writing to [agency’s physical address], or by telephone at [agency’s telephone number]. You agree to hold harmless Agency in connection with your failure to provide current and valid contact information.
By clicking the “I Agree To Electronic Delivery” button below, you confirm that you have read and understood this Consent Form in its entirety, that you consent to the electronic delivery of documents by Agency on its behalf and on behalf of insurers and other third parties, that your hardware and software systems meet the requirements set forth herein, that you are able to access and retain documents presented to you on a portal or via e-mail, and that you have printed or stored a copy of this Consent Form. If you do not agree to the terms of this Consent Form, please click the “I Do Not Agree To Electronic Delivery” button below.
