Consumer Authorization Form

Consumer Authorization Form

ACA Scope of Appointment Form
Important

Every client that you assist must fill this form out at least once.
Client or authorized representative granting authorization:*
Client or authorized representative email:*
example@example.com
Date of birth:*

MonthDayYear
Date
Date that authorization given:*
Assisting agent:*
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.*

YesNo
Signature*

Clear
Should be Empty: