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Please note:

By entering your name, phone number, and clicking "Submit," you are

1) electronically signing this form and

2) consenting to Combined Insurance ("our," "us" or "we") making autodialed calls to you at the landline or wireless phone number(s) you provide.

You are not required to provide such consent as a condition of purchasing Combined Insurance products.

This consent will not be available in paper form; you are encouraged to print this form for your records.

This consent only authorizes us to call you at the phone number(s) you provide in response to this request for information.

If you wish to inquire about Combined Insurance products without submitting your information online,call us at
1 888 234-4466.