1. OUR PLEDGE TO YOU
(Please select your opening company statement.)

	At , one of our top priorities is making sure that the information we have about you is protected and secure. We value our relationship with you and work hard to preserve your privacy and ensure that your preferences are honored. At the same time, the very nature of our relationship may result in us collecting or sharing certain types of information about you. We explain how we use customer information in this privacy policy statement. We invite you to state your choices in the Customer Preferences section. We will honor your selection.
	You have a right to know how information about you is used and protected. Most data remains within the corporate family, and is used to do business with you. Some is shared with others to process your account or for marketing. We explain how we use information in this privacy policy statement. We invite you to state your choices in the Customer Preferences section. We will honor your selection.
	Other	(enter your own company statement below)

2. INFORMATION WE COLLECT
We collect information:
(Please check all that apply.)

	you give to us on applications, surveys, registration forms, etc.;
	you give to us when you make a purchase, or other account information such as balance, payment history or credit card usage;
	you or others give to us about your credit history;
	others give to us to make sure that the data you provide is accurate and up-to-date. This may include information about you from employers, banks, or insurers.
	Other	(please specify below)

3. HOW WE SHARE INFORMATION
(Please check all that apply.)

a.	We do not share information that we have about you with anyone except in response to subpoenas or for other legal reasons. (If you checked "a," proceed to question 4.)
b.	We share information with our affiliates (members of our corporate family) or companies outside our corporate family that perform services on our behalf. We share information to process transactions, respond to your inquiries, or provide information about the products or services that we offer.
	We share (Please check all that apply.) data provided by customers purchase/account data credit history data verifying data other (please specify below)
c.	We share information with companies that we have a special relationship with such as joint marketers.
	We share (Please check all that apply.) data provided by customers purchase/account data credit history data verifying data other (please specify below)
d.	We share information with non-affiliates (companies outside our organization) that would like to offer you their products or services that might be of interest to you.
	We share (Please check all that apply.) data provided by customers purchase/account data credit history data verifying data other (please specify below)
(If you checked nothing under "d," you may check "e.")
e.	We do not share information about you with non-affiliates (companies outside our organization) for them to contact you for their own marketing purposes.
f.	The types of companies that we share information with include
	financial service providers such as       mortgage bankers       securities brokers-dealers       insurance agents       other financial service providers (please specify below)
	In addition, we share information with non-financial companies such as       retailers       magazine publishers       direct marketers       non-profit organizations       other (please specify below)
g.	The law permits us to share information about our current and former customers with government agencies or authorized third parties under certain circumstances. For example, we may be required to share such information in response to subpoenas or to comply with certain laws. (*This statement will automatically be added to your policy notice.)

4. HOW WE PROTECT INFORMATION

	We strive to protect your data and safeguard it from unauthorized individuals.
	Other	(please specify below)

5. FORMER CUSTOMERS

a.	We do not share information about our former customers with anyone except in response to subpoenas or for other legal reasons.
(If you checked "a," proceed to question 6.)
b.	We share information about our former customers with members of our corporate family or companies outside our corporate family that perform services on our behalf.
	We share (Please check all that apply.) data provided by customers purchase/account data credit history data verifying data other (please specify below)
c.	We share information about our former customers with companies that we have a special relationship with such as joint marketers.
	We share data provided by customers purchase/account data credit history data verifying data other (please specify below)
d.	We share information about our former customers with companies outside our organization that would like to offer you their products or services that might be of interest to you.
	We share data provided by customers purchase/account data credit history data verifying data other (please specify below)
(If you checked nothing under "d," you may check "e.")
e.	We do not share information about our former customers with companies outside our organization for them to contact you for their own marketing purposes.

6. CUSTOMER PREFERENCES
(Company can skip this section if it does not share customer information with companies outside its organization nor credit history information with members of its corporate family.)
We honor your choices for sharing data as checked below. Please fill-out this form and return it to us at:

(Company Name)
(Address)
(City)		(State)		(Zip)

(Company must provide customers with the appropriate options as listed below:)

	Please do not share information about me with companies outside your organization. By law, this doesn't include companies that are performing services on our behalf or our financial marketing partners.
	Please do not share my credit history with members of your corporate family.

For joint accounts:
(Company must select "a" or "b" if it has joint account holders.)

a.	We will honor your preferences, and will automatically apply those same choices to the other account holder(s).
b.	We will honor each account holder's preferences separately.
	[] Please apply my preferences to all joint account holders. [] Please accept my preferences and honor the other account holder(s) as follows: Joint account holder name(s): _________________________      [] Do not share information about the joint account holder listed above outside your company.      [] Do not share credit history data about the joint account holder listed above with members of your corporate family. Your Name:_______________________________________________________ Address:_____________________________________________________ City: __________________ State:____________ Zip: _______________ Account/Policy No(s): __________________________________________

(Other options company may provide):

	In addition, you may share with us your preferences by calling us toll-free at: (company toll-free number)
or by emailing us at: (company email address)