Acord Minnesota Authorization
Producer                                                       Applicant's Name and Mailing Address   (Include county & ZIP4)

MN Insurance Brokers, Inc. 
The DORMODY AGENCY
6083 12th St. N.
Oakdale, MN 55128
Pho: 651-731-5358
Fax:  651-731-4047
 First Name: 
Last Name: 
Address:     
City:             State: 
ZipCode:     
 
AUTHORIZATION TO COLLECT AND DISCLOSE PERSONAL
OR PRIVILEGED INFORMATION
(We are required to obtain this authorization from you pursuant to Minnesota Statute 72A.501.)
 

I, the undersigned, hereby authorize the agent named above, if any, and/or the underwriting department of the insurance company named above to collect credit-related and other information about me from the following types of oranizations:

  • Credit Bureaus
  • Other organizations providing personal or privileged information

I understand this information will be used for the purpose of making underwriting decisions in connection with the insurance for which I have applied, sought reinstatement or requested a change in benefits. These decisions may include determinations to grant or deny me coverage and/or the rates I will be charged.

I understand that this temporary authorization will expire as soon as one of the following occurs;

  • The above-named company makes the underwriting decision(s) in question, or
  • One year elapses after the date I sign this authorization
 
  APPLICANT/NAMED INSURED'S
SIGNATURE : 		    Applicant Name :
   
 
        E-Mail Address:
   
 
        Date:
   
 
 
  DISCLAIMER: I understand that submission of this form indicates that I have read and understand the Minnesota Notice of Information Practices (Privacy). Submission of this form gives express premission to MN Insurance Brokers, the Dormody Agency and the insurance companies from whom they will request quotes, to use a credit score when preparing the quote.