Request a Quote Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Preferred Method of Contact Phone Text Email Insurance Type* Home Commercial Financial Description*Tell us a brief description of your insurance needs OUR PRIVACY POLICIES AND PRACTICES 1. Information we collect: We collect nonpublic personal information about you from the following sources: Information we receive from you on applications or other forms. Information about your transactions with us, our affiliates or others. Information we receive from a consumer reporting agency. Unless it is specifically stated otherwise in an amended Privacy Policy Notice, no additional information will be collected about you. 2. Information we may disclose to third parties: We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law. 3. Nonaffiliated third parties to whom disclosures may be made: We disclose nonpublic personal information about you only to non-affiliated third parties as permitted by law. 4. Our practices regarding information confidentiality and security: We restrict access to nonpublic personal information about you to those employees who need to know that information in order to provide products or services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. 5. Our policy regarding dispute resolution: Any controversy or claim arising out of or relating to our privacy policy, or the breach thereof, shall be settled by arbitration in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. 6. Reservation of the right to disclose information in unforeseen circumstances: In connection with the potential sale or transfer of its interests, Mead-Maloy Agency, Inc and its affiliates reserves the right to sell or transfer your information (including but not limited to your address, name, age, sex, zip code, state and country of residency and other information that you provide through other communications) to a third party entity that (1) concentrates its business in a similar practice or service; (2) agrees to be Mead-Maloy Agency, Inc’s successor in interest with regard to the maintenance and protection of the information collected; and (3) agrees to the obligations of this privacy statement. 7. Customer acknowledgement and signature: By signing my name below, I am indicating that I have read the privacy policy of Mead-Maloy Agency, Inc and that I understand its terms. No promises or representations have been made to me to induce me to sign this form. Signature Δ Please be advised that insurance coverage cannot be added, deleted or otherwise changed until it is confirmed in writing by Mead-Maloy Agency/Ely & Leene Agency or your insurance carrier.