Emergency Contacts

Emergency Contact Permission to Contact Form for
Earl Simons Agency

Thank you for accepting the responsibility of being an Emergency
Contact for one of our customers. This is a very important tool in
helping us to be there when our customers need us most!

Our agency standard is to receive permission from you before using
your cell number to contact you, sending you a text message or
email, and before using an automated dialer tool to leave you an
automated message.

We often use an automated dialer and a text message asking you
to call in to validate your Emergency Contact Status, as well as to
extend you birthday and holiday wishes.

Please answer the questions below. The entire process usually
takes 30 seconds!

Customer that selected you? *

Your Email *

Your First name *

Your Last name *

Your Cell Phone *

Additional Info

By clicking the subscribe button I acknowledge and understand that it constitutes
express written consent that Earl Simons Agency can contact me using the contact
information I provided on this form, for the purposes stated above, by a combination
of live calls, automated calls, emails, or text message.

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