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Earthquake Protection Unit Authorization Form

I affirm I am the owner of the residence indicated below, and I have both a homeowners and earthquake insurance policy covering this residence through AIG Private Client Group, a division of the member companies of American International Group, Inc. (AIG). I hereby authorize vendors and employees of my insurance company (the "Service Providers") to assess the exterior of my property and if necessary, assess if a mitigation vendor should be sent to my home and file a claim on my behalf ("Service"). The intent being that these Services provided by Service Providers may reduce the risk of further loss or damage to my property.

I understand that once I sign this authorization, the Service Providers may access the exterior of my house at any time after an earthquake in order to provide the Services.

I understand and acknowledge that the Services provided by the Service Providers may not prevent damage to my property or residence. I also understand that there is no guarantee that the Service Providers will be able to provide the Services to my property. I AGREE THAT THE SERVICES PROVIDED ARE "AS IS" AND THAT MY INSURANCE COMPANY AND THE SERVICE PROVIDERS SPECIFICALLY DISCLAIMS ALL WARRANTIES TO THE SERVICES EXCEPT AS SPECIFICALLY STATED HEREIN.

I understand that as a policyholder I will not be charged for this Service; the Earthquake Protection Unit will submit a claim on my behalf to cover the fees for this Service. The claim will be coded as catastrophe related so there will be no adverse rating in my claim history. AIG Private Client Group has the right to terminate this Service at any time and for any reason. I understand that this Service will automatically terminate if I am no longer a policyholder. I also understand that my participation is totally voluntary.

I understand that AIG Private Client Group and Service Providers will make every effort to reach enrolled policyholders affected by earthquakes, but cannot guarantee this in all circumstances.

* Required Fields. Please do not use commas or other symbols.

By checking this box, I hereby agree to the above terms.

NOTE: This service is only available to policyholders residing in one of our pre-approved California areas. Policyholders must have BOTH homeowners and earthquake coverage to be eligible. 

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This information will only be used by AIG Private Client Group and only for the purposes of contacting you during an emergency situation. We will not use or share this information for any other purpose other than for this program.

Please provide at least one phone number where you can be reached in an emergency:

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Numbers only; no special characters

Additional contact numbers (at least one number is required):

(Numbers only, no special characters)
(Numbers only, no special characters)
(Numbers only, no special characters)
(Numbers only, no special characters)
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(An e-mail confirmation will be sent to this address)

Alternate contact person during an emergency:

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Alternate contact person during an emergency
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Alternate contact phone for during an emergency
 

Contact person for non-emergency related issues including complimentary onsite consultation: