Electronic Mail Consent - First Benefits Insurance Mutual

Receiver of Electronic Records:

The following individual is an authorized official of the named insured’s business and is approved to receive Electronic Records from First Benefits Insurance Mutual via email and to access policy information within the Policyholder Portal.

Business Legal Name *

Policy Number *(Call 919-977-1773 if needed)0 / 13

Business Mailing Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Primary Business E-mail Address *(Where to receive future correspondence)

Signature *

Title *

Receiver of Electronic Records:

The following individual is an authorized official of the named insured’s business and is approved to receive Electronic Records from First Benefits Insurance Mutual via email and to access policy information within the Policyholder Portal.

Business Legal Name *

Policy Number *(Call 919-977-1773 if needed)0 / 13

Business Mailing Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Primary Business E-mail Address *(Where to receive future correspondence)

Signature *

Title *