Emergency Contact Permission to Contact Form
Thank you for accepting the responsibility of being an Emergency Contact for one of our customers. This is a very important tool in helping us to be there when our customers need us most!

Our agency standard is to receive permission from you before using your cell number to contact you, sending you a text message, and before using an automated dialer tool to leave you an automated message. (We often use an automated dialer and a text message asking you to call in to validate your Emergency Contact Status, as well as to extend you birthday and holiday wishes) Please answer the questions below. The entire process usually takes 30 seconds!
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What is the first name of the customer that selected you to be their emergency contact? *
What is the last name of the customer that selected you to be their emergency contact? *
What is your first name? *
What is your last name? *
What is the best contact number to reach you to discuss Emergency Contact related items? *
We will primarily make live calls to this number however; there might be situations in which we use automated dial technology.
If you provided a cell number, may we text message you?
(Generally, no more than 3 text messages per year)
Clear selection
If you did not provide a cell number but would like to, please do so below:
Would you like to provide us with any additional contact information such as an additional email address, mailing address, or phone number? If yes, please input the information in the box below
By clicking the submit button I acknowledge and understand that it constitutes express written consent that the ???????? insurance agency can contact me using the contact information I provided on this form, for the purposes stated above, by a combination of live calls, automated calls, or text message as selected by me.
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