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Release of Authorization Form: River Valley Insurance Group, Inc. - Madison, Indiana

 

I hereby authorize River Valley Insurance Group, Inc., Inc. to obtain various insurance reports, including, but not limited to, Motor Vehicle Reports, CLUE Reports (loss history information for auto and home) and Insurance Scores.

I understand that the information found on these reports may have an impact on the actual premium quoted.

Name
First M. Last
Date of Birth
00/00/0000
Social Security #
000-00-0000
Drivers License #
0000-00-0000
Address
123 S. Main
City
Anywhere
State
IN
ZIP
47250
Phone #
123-45-6789
EMAIL
anyone@abc.com
   
Spouse
 
Spouse's Name
First M. Last
Spouse's Date of Birth
00/00/0000
Spouse's Social Security #
000-00-0000
Spouse's Drivers License #
0000-00-0000
Additional Drivers
 
Name
First M. Last
Date of Birth
00/00/0000
Drivers License #
0000-00-0000
   
Name
First M. Last
Date of Birth
00/00/0000
Drivers License #
0000-00-0000
   

TERMS AND CONDITIONS:

PRIVACY STATEMENT:  IN CONNECTION WITH THIS PROPOSAL FOR INSURANCE, MOTOR VEHICLE REPORTS, CLUE REPORTS AND A CREDIT REPORT OR A CREDIT BASED INSURANCE SCORE MAY BE ORDERED AND REVIEWED.  THE RESULTING INFORMATION MAY BE USED TO DETERMINE THE RATE THAT YOU ARE CHARGED FOR INSURANCE. WE MAY USE A THIRD PARTY IN CONNECTION WITH SECURING THESE REPORTS AND THE DEVELOPMENT OF YOUR INSURANCE SCORE. 

By checking this box and signing initials, I have read, understand and agree to all terms and conditions listed above. initials

 

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