Chicago Il Insurance

NOTICE: No risk is bound until a policy is written or binder issued.

I authorize Lincoln Insurance Agency, Inc. to take the following actions on my behalf, if Lincoln believes such actions to be in my best interest: (1) sign premium financing agreement with Lincoln Acceptance Company, covering types of insurance requested by me; and (2) sign applications and other forms and documents necessary to procure, renew, substitute or amend insurance and travel club memberships requested by me. Lincoln Insurance Agency, Inc., Lincoln Acceptance Company, Lincoln Travel Club, Inc. are all affiliated companies under common ownership.

Dated this day of, 20

X

Signature

LINCOLN INSURANCE AGENCY, INC.

855 W Washington Blvd Chicago, IL 60607 Phone 312-***-**** For Office use only.

11 FEBRUARY 24

7534 S COLES AVE APT 2

CHICAGO IL 60649-4399 WARREN CALHOUN

Reference #: 541553/BATCHUSR

Printed 02/18/24 at 12:30

Account/Lead #: 541553

Contact this candidate