McHenry Insurance
Electronic Disclosure and Consent Form

Yes, I would like to receive my policy and endorsements for my Insurance policies electronically!

This Electronic Disclosure and Consent form contains information about how we will deliver your policy information, disclosures and applicable account notices electronically as required by applicable law.

Consent to Electronic Delivery.  By signing below, you consent to receive and acknowledge that you can access, receive and retain all notices, statements, and disclosures electronically whether sent by e-mail or other electronic means and acknowledge that you will no longer receive paper copies. You are not required to do business electronically.

Electronic Policy Information. By signing below, you acknowledge that you would prefer to receive your policy through your email account.

If you currently receive a combined statement for your accounts you acknowledge and agree to receive notices, statements and disclosures electronically for all of the other accounts appearing on the combined statement.

You may request a paper copy of any policy by contacting our office at 406-586-5075.

You will have the option to download a complete copy of your policy information and other Transaction information in an Adobe Acrobat PDF File.

To download and view your documents using the Adobe Acrobat PDF File, Adobe Acrobat Reader must be installed on your system. Adobe Acrobat Reader DC is available for free download from www.adobe.com. (look in the lower right corner)

Withdrawal of Consent to Electronic Notices and Statements. If you agree to receive policies and endorsements electronically you can withdraw your consent at any time by writing to our office at 406-586-5075. Upon written withdrawal of consent, you will begin receiving paper policies immediately. Withdrawal of your consent will not affect the legal validity and enforceability of any policy statement or disclosure previously received electronically.

Notification of Changes. You agree to notify us promptly if your mailing address, e-mail address or other information changes by contacting our office at 406-586-5075.

I consent to the use of Electronic Records in connection with my insurance policy. I have been able to read this notice using my computer software. I have successfully printed or downloaded a copy of this notice. I have access to an account with an Internet service provider, and I am able to send and receive e-mail. [I am consenting on behalf of all joint applicants identified in the application. I am authorized to consent on their behalf.]

I consent to receive my policy and endorsements for my Insurance

X: _____________________________

I do not want to conduct this transaction electronically

X: ____________________________________

 If you wish to print this page, sign and fax. Please fax to 406-582-0697

Or you may email signed consent to mchenry@mchenryins.net