Loss Control Opt Out Form

SELECT ONE OR BOTH OPTIONS BELOW TO REMOVE SPECIFIED INDIVIDUALS FROM OUR MAILING LIST. THIS APPLIES TO ALL ELECTRONIC AND/OR PAPER PROMOTIONAL ITEMS SUCH AS FLYERS, BROCHURES, NEWSLETTERS, AND ADVERTISEMENTS. *

ELECTRONIC MAILINGS

PAPER MAILINGS

MAILING CODE (the number located on the first line of the mailing address from the item you received) *

SPECIFY WHO SHOULD BE REMOVED FROM OUR MAILING LIST *

REMOVE ALL COMPANY EMPLOYEES

REMOVE ONLY THOSE EMPLOYEES SPECIFIED BELOW

COMPANY NAME *

FIRST NAME *

LAST NAME *

EMAIL ADDRESS *

FIRST NAME

LAST NAME

EMAIL ADDRESS

FIRST NAME

LAST NAME

EMAIL ADDRESS

FIRST NAME

LAST NAME

EMAIL ADDRESS

FIRST NAME

LAST NAME

EMAIL ADDRESS

I AM AUTHORIZED TO REQUEST THESE CHANGES ON BEHALF OF THE COMPANY. I UNDERSTAND THAT BY OPTING OUT OF THE MAILINGS SPECIFIED ABOVE, IT IN NO WAY CHANGES THE EMAIL OR REGULAR MAILING OPTIONS FOR OTHER FORMS I MAY RECEIVE FROM NATIONAL AMERICAN INSURANCE COMPANY WITH REGARDS TO INSURANCE POLICIES, CLAIMS, ACCOUNTING OR OTHER LEGAL MATTERS. I UNDERSTAND IT CAN TAKE UP TO 30 DAYS FOR MY REQUEST TO TAKE EFFECT.

NAME OF AUTHORIZED PERSON (FIRST AND LAST) *

EMAIL ADDRESS *