CONSUMER INSURANCE INFORMATION SHEET


The purpose of this form is to provide Consumer Select Insurance of America (CSIA) with explicit permission to contact me(us) at the address and phone number below to help us shop for insurance related to this transaction or other insurances I(we) may request:

Must be completed by the person or persons who desire to be contacted, not that person’s agent or any other individual.


BUYER(S)

Buyer's Name:
Buyer's Current Home Address:
Buyer's City:
Buyer's State:
Buyer's Zip:
Buyer's New Home Address:
Buyer's New City:
Buyer's New State:
Buyer's New Zip:
Buyer's Current Home Phone:
Buyer's Current Fax Number:
Buyer's E-Mail Address:
Type of Insurance:
I (we) understand that this information will only be used for the purposes stated above in full compliance with the CSIA Privacy Policy and that I (we) have chosen to be contacted by CSIA.