OPT-IN FORM FOR TEXT MESSAGING

The undersigned client "You" consents to receive text messages from Town & Country Insurance or others acting on the Agency’s behalf.  As part of this consent, you represent and warrant the following:

(1) You understand that no coverage may be bound or amended via text message.

(2) The Agency or others acting on the Agency's behalf may send text messages in various formats and with various contents,  including but not limited to, text messages about insurance policies and other transactions initiated by You or marketing the products and services offered by or through the Agency.

(3) You are the owner or authorized user of the mobile phone number identified below.  You will notify us immediately if you are no longer the owner or authorized user of the mobile phone number identified below.

(4) You are solely responsible for any message and data charges associated with such text messages.

(5) The Agency has made its Text Messaging Terms and Conditions ("Terms and Conditions") available to you on its website, and will provide you with a hard copy of the Terms and Conditions upon request.  By signing this opt-in form, you agree to the Terms and Conditions.

(6) If you sign this opt-in form, you will receive an initial text message to the mobile phone number below asking you to confirm your consent with an Opt-in or Opt-out response.

If you do not wish to receive text messages from the Agency or others acting on the Agency's behalf, or do not agree to the Terms and Conditions, You should not sign this form.