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By sending this information, I understand that Village Insurance Brokers or any insurer, to whom Village Insurance Brokers submit my application may collect, use and disclose personal information from me and about me for the following purposes: 1) To understand my needs. 2) To analyze the suitability of my insurance and financial services for me. 3) To determine my eligibility for products and services. 4) To set up, manage and offer products and services that meet my needs. 5) To provide me with ongoing service. 6) To meet legal and regulatory requirements. 7) To facilitate underwriting my insurable risks and insurance claims. Withdrawal of Consent: You may generally withdraw your consent at any time. If you refuse or withdraw your consent to the collection, use or disclosure of information about you, we may not be able to provide or continue to provide you with some products, services or information of value to you.

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