This site was designed for the latest version of Chrome, Firefox, Safari, and Internet Explorer (version 10+). Some features may not work correctly in your browser. OK

Site Usage Disclaimer & Privacy Policy

Opt In/Opt Out Form:

Customer has the right to Opt-Out of any of these Customer NPI disclosures, other than Customer NPI disclosures that are permitted by law. If you wish to Opt-Out of disclosures to non-affiliated third parties, then you must follow the instructions below. A completed Opt-Out form will automatically apply to all members of any associated joint account holders. Steve Schmitt Inc restricts unauthorized access to Customer NPI using commercially reasonable safeguards and protections in compliance with Federal Regulations. If you wish to Opt-Out of Customer NPI disclosures to non-affiliated third parties, then you must print out this form and completely and accurately fill it out, sign the form below and drop it off in person or mail it to the address listed herein: Steve Schmitt Inc, 12631 State Rt. 143, Highland, IL, 62249.

 

Please Check Only One Of The Following Boxes:
Opt-In ___ I wish to Opt-In regarding the disclosure of Customer NPI as defined by the provisions listed herein
Opt-Out ___ I wish to Opt-Out regarding the disclosure of Customer NPI as defined by the provisions listed herein
Should you have any questions regarding this Privacy Policy please contact Steve Schmitt Inc, 12631 State Rt. 143, Highland, IL, 62249, (618) 654-2181.


Customer's Signature

Joint Customer's Signature (if applicable)

Customer's Printed Name

Joint Customer's Printed Name (if applicable)

Customer's Street Address

Vehicle's 17-Digit Vehicle Identification Number

Customer's City/State/Zip

Vehicle's Year Make Model

Customer's Phone Number

Today's Date
- + Disclaimers