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VENTURE
GENERAL AGENCY LLC
ELECTRONIC SIGNATURE AGREEMENT AND DISCLOSURES
Policy No. VGAL-105349-000
In order to obtain auto insurance with Old American County Mutual Fire Insurance Company through Venture General Agency, LLC,
insurance applicants may be required to answer certain questions on the application by key pad, mouse or other device used to select an
item, button, icon or similar act/action. All questions were answered by me personally or answered on my behalf with my expressed
consent, agreement to, and approval of the response given. Further, my electronic signature was affixed to the application only after I
had read, understood and agreed to the terms proposed therein.
Applicants may also be required to use an electronic signature when such signature is necessary on the application. You acknowledge and
agree to the use of this electronic service in accessing or making any transaction regarding any application or policy for auto insurance
through Venture General Agency, LLC.
The Insured's Signature below further reflects the insured's choice as required by section 1952.101 through 1952.110 of the Texas
Insurance Code, regarding Uninsured/Underinsured Motorist Benefits and as required by Section 1952.152 through 1952.161 of the Texas
Insurance Code, regarding Personal Injury Protection as indicated by the electronic signature on the application for Automobile Insurance.
Con el fm de obtener un seguro de automovil con Old American County Mutual Fire Insurance Company por medio de Venture General
Agency, LLC, los solicitantes podran ser obligados a responder a ciertas preguntas de la aplicacion por medio del teclado, mouse o otros
dispositivos utilizados para seleccionar un articulo, boton, un icono o acto/accion similar.
Los solicitantes tambien pueden ser requeridos a utilizar una firma electronica cuando dicha firma es necesaria en la aplicacion. Usted
reconoce y acepta el use de este servicio electronico para acceder o hacer cualquier transaccion concerniendo la aplicacion o poliza de
seguros de auto por medio de Venture General Agency, LLC.
Para completar la solicitud de seguros de auto con Old American County Mutual Fire Insurance Company por medio de Venture General
Agency, LLC, conteste las preguntas determinadas de la aplicacion y seleccione las respuestas correctas por medio del teclado, mouse o
otros dispositivos utilizados. Ademas, he colocado mi firma electronica cuando fue necesaria en la aplicacion. Todas las preguntas fueron
respondidas por mi, personalmente o respondidas con mi consentimiento expresado, estoy de acurdo, y doy mi aprobacion a las respuestas
dadas. Ademas, aplique mi firma electronica solo depues de que yo habia leido, comprendido, y aceptado los terminos propuestos.
The following statement only applies to policies that begin with
VGAL
My signature below also verifies that I have been informed both verbally and in writing of the following statement:
WARNING: A NAMED DRIVER POLICY DOES NOT PROVIDE COVERAGE FOR INDIVIDUALS
RESIDING IN THE HOUSEHOLD THAT ARE NOT NAMED ON THE POLICY.
ADVERTISIO: UN CONDUCTOR MENCIONADO EN LA POLIZA NO PROVEE COVERTURA A LAS
PERSONAS QUE EN EL HOGAR DEL ASEGURADO QUE NO SON MENCIONADES EN LA POLIZA DE
SEGUROS.
Named Insured Signature
Date 08/24/2016
PLEASE ATTACH TO POLICY OR FAX IMEDIATELY TO VENTURE GENERAL AGENCY
855-480-3756
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GENERAL AGENCY LLC
Privacy of Non-Public Financial Information
Venture General Agency represents licensed insurers and through its producers requests
and obtains from consumers and customers nonpublic personal financial information, as
defined below ("Nonpublic Personal Financial Information"), for use in connection with
providing certain insurance products.
It is understood Nonpublic Personal Financial Information includes personally identifiable
financial information and any list, description or other grouping of consumers, and publicly
available information pertaining to them, that is derived using any personally identifiable
financial information that is not publicly available. "Personally identifiable financial
Information" means any information a consumer provides Venture General Agency to obtain
a financial product or service, information otherwise obtained about a consumer in
connection with providing a financial product or service to that consumer, and any
information about a consumer resulting from any transaction involving a financial product or
service between Personable and a consumer. Personally identifiable financial information
includes a consumer's name, address, zip code, email address, phone number, credit
history, social security number, driver's license number, date of birth and any other
information that itself identifies, or when tied to the above information, may identify a
consumer.
Pursuant to the Gramm-Leach-Bliley Act of 1999 (the "GLB Act") and state insurance laws
and regulations promulgated thereunder requiring that financial institutions develop policies
to protect the confidentiality of Nonpublic Personal Financial Information, Venture General
Agency has prepared a privacy notice regarding its privacy practices, which may be
amended from time to time in accordance with the GLB Act and the state insurance laws
and regulations of those states in which products are sold (the "Privacy Notice"). The
Privacy Notice is provided to consumers and states that (1) Venture General Agency does
not disclose any Nonpublic Personal Financial Information to any third party except as set
forth in the Privacy Notice; and (2) the Privacy Notice does not provide the consumer an
opportunity to opt out of disclosure of their Nonpublic Personal Financial Information for
purposes of the GLB Act.
The Privacy Notice is sent to all insureds at the inception of their insurance policy and
annually thereafter as long as the insurance policy remains in force. Venture will not
disclose or use Nonpublic Personal Financial Information obtained other than in connection
with the duties and obligations set forth in the insurance contract and in connection with
servicing and processing a product that a consumer requests or authorizes in the ordinary
course of business and except as otherwise set forth in the Privacy Notice or as otherwise
provided by applicable federal and state laws and regulations.