Emergency Contact Program Application
Disaster Prevention Form
Print this page and mail or fax it in. Or, copy and paste into an email, fill out, and send to thebalcosbrothers@balcosinsurance.com.
1. Update your contact information.
If an emergency does occur, we want to be able to reach you quickly, so let’s make sure we have the most current ways to get in touch with you. Can you take a moment and get this information to us right away? Thanks!
Your Name:
Co. Name:
Address:
Home Phone:
Business Phone:
Email:
Mobile Phone:
2. Your EMERGENCY CONTACTS’ information.
Please list the name(s) of at least one or more neighbors, relatives, trusted friends or colleagues who can serve as your EMERGENCY CONTACT (their name will be held in confidence in your personal file). If something does go wrong, it may be the most important thing you’ve done!
As a complimentary gift to your EMERGENCY CONTACT, we’d like to offer them a FREE insurance consumer report. Please mark which (you may mark more than one) they should receive.
Their Name:
Relationship: (suggested: neighbor)
Address:
City, State, Zip:
Home Phone:
Work Phone:
Email:
Cell Phone:
Send Consumer Report on: Auto Home Business Avoiding Lawsuits
Their Name:
Relationship: (suggested: neighbor)
Address:
City, State, Zip:
Home Phone:
Work Phone:
Email:
Cell Phone:
Send Consumer Report on: Auto Home Business Avoiding Lawsuits
Their Name:
Relationship: (suggested: local relative)
Address:
City, State, Zip:
Home Phone:
Work Phone:
Email:
Cell Phone:
Send Consumer Report on: Auto Home Business Avoiding Lawsuits
FAX TO: 206-783-4408 or
MAIL TO: 8746 Mary Ave NW, Suite #2, Seattle, WA 98117
If you’d like to add more family or friends to your Emergency Contacts, please feel free to add another sheet.
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