Consumer Authorization Form
ACA Scope of Appointment Form
Important
Every client that you assist must fill this form out at least once.
Client First Name:
Name
*
First Name
Last Name
Client or authorized representative email:
*
example@example.com
Date of birth:
*
-
Month
-
Day
Year
Date
Date that authorization given:
*
Assisting agent:
*
Please Select
Gerard Denys
Kris Hardy
Kim Lawler
Karen Midland
Sheena Joyce
Joan Cox
Danielle Giamo
Brenda George
Dan Lyonnais
Brett Harper
John Tracy
Chase Johnson
Cori Kish
Lorraine Hayes
Nancy Smith
Amy Devor
Brooke Miller
Mercedes Perez
Jeffrey Kahler
Varsha Narotam
Lorrie Blandy
Aaron Denys
Jason Jackson
Tina Wellman
Maghan Magruder
Jason Miller
Talena Thompson
Deirdre Murphy
Megan Freeland
Beth McQuillen
Chris Norman
Jessica Zackery
Reeva Pierre
Carl Mastropolo
Kalishia Key
Christina Moriarty
Denise Bloodsworth
Leeshel Gaines
I give my permission to Berlin & Denys Insurance and their licensed agents to maintain, store, and/or use my PII in order to carry out the roles and responsibilities of a licensed sales agent. I understand that they might need to create, collect, disclose, access, maintain, store, and/or use some of my PII in order to provide this assistance. I may revoke this authorization at any time by notifying Berlin & Denys Insurance or my agent. Once I have signed this authorization form, I can expect Berlin & Denys Insurance and my agent to assist me without needing to sign another authorization form.
*
Yes
No
Signature
*
Submit
Should be Empty: