If you choose to exercise your right to opt out, you must print out, sign, date and return this form to The Schonning Insurance Agency at PO Box 1488, Westerly, RI 02891. If you return this form to us by mail, your response must be postmarked no later than 30 days from the date you printed this notice from us in order for it to be valid. If you do not return this form to us within 30 days, you have not exercised your opt out right, and we can share the information described.

I wish to exercise my right under the Gramm-Leach-Bliley Act to opt out of The Schonning Insurance Agency's sharing nonpublic personal information about me to non-affiliated third parties for purposes other than those that are permitted by law.

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Please print Name

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Customer Signature / Date