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Privacy Statement

As indicated by the signature(s) on this form, I (we) have been advised and have full knowledge that in applying for insurance with TOTAL INSURANCE SOLUTIONS, Illinois providing   Auto  insurance coverage, I (we) are paying to TOTAL INSURANCE SOLUTIONS a one-time, non-refundable service charge of  $60.00  dollars, as authorized by Sec. 500-80 of the Illinois Insurance Code. I (we) further understand and agree that should the application for insurance be rejected, postponed, canceled, rated up, or should I (we) elect for any reason to withdraw or cancel the application for insurance or request the coverage be canceled or the application voided, the service charge is fully earned and that no portion of the service charge will be refunded or returned.

I (we) further agree and understand that if payment for said insurance or application is by personal or business check and should that remittance be returned by any financial institution as non-negotiable for any reason, I (we) agree we will be obligated to pay immediately in cash, cashier’s check, or money order an additional service fee to TOTAL INSURANCE SOLUTIONS the sum of Twenty-Five ($25.00). I (we) understand and agree this fee is in addition to any premiums due and payable and is due TOTAL INSURANCE SOLUTIONS regardless of the status of the application or request for insurance services.