Emergency Contact Selection Form for Ley Insurance Agency

It is very important that someone who does not live in your home has your insurance agent's contact information easily accessible inside of their cell or mobile device.

Customer: Please make sure that someone who does not live in your home is designated as having the ability to contact the agency in event of an emergency, and you are unable to contact us. ALWAYS ask them to save the agency's contact information in their cell or mobile device.

If it is easier for you, you can provide the Emergency Contact's information below and one of our team members will contact them to verify that they have the agency's information saved in their mobile device.

Selected Emergency Contact: Thank you for accepting the responsibility of being an Emergency Contact for one of our customers. This is a very important tool in helping us to be there when our customers need us most! 

Our agency standard is to receive permission from you before using your cell number to contact you, sending you a text message, and before using an automated dialer tool to leave you an automated message. 

We often use an automated dialer and a text message asking you to call in to validate your Emergency Contact Status, as well as to extend you birthday and holiday wishes.

Please answer the questions below. The entire process usually takes 30 seconds!

Emergency Contact Form

By clicking the submit button I acknowledge and understand that it constitutes express written consent that Ley Insurance Agency can contact me using the contact information I provided on this form, for the purposes stated above, by a combination of live calls, automated calls, or text message as selected by me.

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