AUTHORIZED REPRESENTATIVE

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By filling in my Name and Title above, I acknowledge that I am providing information that may be used to evaluate my application for an insurance policy and for other purposes set forth in the Privacy Statement and the Legal Notices found at the following links: http://www.bbinsurance.com/privacy.shtml and http://www.bbinsurance.com/legal.shtml. Further, by filling in my Name and Title above, I certify that I have read, understood and accepted each of the Privacy Statement and Legal Notices.

Must provide quotes in writing or via e-mail, not orally.