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Electronic Disclosure Notice

Nonprofit Insurance Services

Electronic Disclosure Notice


Disclosure and Consent to Receive Electronic Records

Please read this document carefully, and print a copy and/or retain this information electronically for future reference.

Definitions.

The following words and phrases shall have the meanings given to them, unless the context clearly indicates otherwise:

“Agency”: B.A. Barrick & Co., Inc. DBA Nonprofit Insurance Services, P.O. Box 933, Hanover, PA 17331

“Agreement”: This Consent to Receive Electronic Records form.

“Insurer”: An insurance company issuing a policy and bearing the risk.

“Policy”: A contract of insurance purchased through an agency between an insurer and insured.

“Records”: Any and all disclosures, declarations, contracts, policy forms, certificates and/or documents, information, requests, applications, communications, and/or notices required by federal law, including, but not limited to, any adverse action notices or privacy policy notices.

“You”: The Insured.

Introduction.

From time to time, the agency may, whether on its own behalf and/or on behalf of an Insurer and/or third-parties, utilize the Internet, email, digital media or the like to transmit records and/or related information to policyholders. This agreement informs you of your rights when conducting these transactions electronically with this agency, an insurer, and/or those third-parties from whom we may receive and/or transmit your records.

Hardware and software requirements.

Before agreeing to receive records electronically, You must determine if you have the necessary hardware and software to access and retain these records electronically. To access your records, you will need an electronic mailing address, Adobe Acrobat Reader, and a personal computer or other device which is capable of accessing the internet. To retain your records, your access device must have the ability to download to your hard drive, or any external media storage, or to print the records, as well as embedded HTML files.

If, after you have consented to the terms and conditions of this agreement, a change in the hardware or software requirements needed to access electronic records creates a material risk that you will not be able to access or retain subsequent electronic records which are the subject of this agreement, upon request we will provide you with a statement of the revised hardware and software requirements for access to, and retention of, the electronic records and the right to withdraw your consent without imposition of any fees for such withdrawal, and without imposition of any condition or consequence that was not disclosed under this agreement.

Consent applies to categories of Records.

Your consent to receipt of electronic records applies to any and all records, policy documents, certificates, applications and/or any information or electronic communications related to your policy, with the exception of the cancellation or termination of health insurance or benefits or life insurance benefits (excluding annuities). You will receive any records required by federal law at this website, or through the electronic mail address you provide.

Option to obtain paper copies of Records.

You have the option to request that we provide you with paper copies of those records we provide to you electronically at this website, or through the electronic mail address you provide. If you wish to obtain the records in non-electronic form, send your request to this agency via email to info@insureanonprofit.com, and provide your mailing address. In the alternative, you may send your request to obtain the records in non-electronic form to the agency at our postal address set forth above. We will not charge you for the paper copies of the records.

Right to withdraw consent and procedures for withdrawal.

You may withdraw your consent to receive your records electronically at any time by sending an email to the following address: info@insureanonprofit.com. Alternatively, you may send your withdrawal of consent to receive your records electronically to the agency at our postal address set forth above. With the exception of email communications, your transaction will continue to be processed in non-electronic form at no charge. Withdrawal of your consent shall not affect the legal effectiveness, validity and/or enforceability of electronic records provided or made available to you prior to implementation of your withdrawal of consent. Your withdrawal of consent shall be effective within thirty (30) days after receipt by the agency of your withdrawal request.

Updating your contact information.

To update your electronic or mailing address, contact us via email at info@insureanonprofit.com.

By consenting below, you acknowledge receipt of this agreement, and agree to the electronic delivery of your records at our website, or through the electronic mail address you provide.

CONSENT AND ACKNOWLEDGMENT.

BY AFFIRMATIVELY RESPONDING TO THIS ELECTRONIC RECORD, YOU ACKNOWLEDGE THAT YOU CAN ACCESS AND RETAIN THE ELECTRONIC RECORDS IN THE FORMAT DESCRIBED ABOVE, AND YOU CONSENT TO HAVING THE AGENCY, WHETHER ON ITS OWN BEHALF AND/OR ON BEHALF OF AN INSURER AND/OR THIRD-PARTIES, PROVIDE RECORDS TO YOU ELECTRONICALLY VIA EMAIL OR OTHER ELECTRONIC MEDIA. YOU ACKNOWLEDGE THAT YOUR POLICY, AND ANY AND ALL POLICY RECORDS, WILL BE DEEMED TO HAVE BEEN DELIVERED TO YOU IF THEY ARE SENT TO YOUR EMAIL ADDRESS AS SET FORTH BELOW, OR VIA ANY OTHER METHOD OF DELIVERY IN THE SPECIFIED FORMAT.

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