If you choose to exercise your right to opt-out, you must mail this completed form to:
Henry’s Insurance Agency, Inc.
Your completed form will be valid from the first business day after its receipt until the
date that we receive your rescission in writing.
If you elect to opt-out, you can do so by checking either or both of the statements below:
____ I request my information not be disclosed to other insurance entities
(whether affiliated or unaffiliated). I understand this may prevent Henry’s from
providing or obtaining any quotation or the most competitive insurance quote.
____ I request my information not be disclosed to any affiliated non-insurance
third party financial service company.
___________________________________ Date:__________________
PLEASE PRINT:
Full Name: __________________________________________________________________
Street Address: _______________________________________________________________
City: ______________________________________ State:_____________ Zip Code:______
7500 Marlboro Pike Suite C
Forestville, Maryland 20747
Attn: Customer Inquires
Signature