Text Messaging Authorization

By filling out the below form, I am authorizing Insurance Service Center – De Pere, LLC to add text messaging as another method to contact me. I understand ISC will continue to use mail, e-mail, and/or phone calls in addition as needed. I understand that texting is not secure.

I understand that text messages are not secure. I will not send private information (such as medical or financial information) through texts or emails.

By entering information into this web form, I acknowledge and agree to the Terms and Conditions above.

Important

To allow texting communication from ISC please fill out the information below.

Name*

First NameLast Name

Choose one:

Yes, ISC agents/staff have permission to text any of my mobile numbers.Limited / ISC may text only the following numbers:No, ISC may not send text messages to me.

List the Phone Number(s) ISC may use to send text messages:*

I CONSENT to Insurance Service Center - De Pere, LLC contacting me via text messages.*

Yes, I consentNo, I do not consent

By sending this Authorization Form to Insurance Service Center - De Pere, LLC, I acknowledge:

I am the owner of the account(s).
I agree to keep Insurance Service Center - De Pere, LLC informed of my current Cell Phone number and will notify them if the number is no longer in my possession.
Additionally, by sending this request and authorizing communication by text messaging, I understand that Insurance Service Center - De Pere, LLC (ISC) cannot guarantee the security or privacy of confidential information when communicating by text messaging.
I will NOT send private information to ISC via text. This would include information such as dates of birth, drivers license, medical or financial information.
I understand I may OPT out of text messaging at any time by replying STOP or calling ISC at 920-337-9345 or mailing us at ISC 436 Main Avenue, De Pere, WI 54115.

Signature*

Date

Text Messaging Authorization Form