ANNOUNCEMENT:

In the event of a forecasted weather event, Clarion may have an early closure and/or a delayed opening for the safety of our office staff. Customer requests and calls will be answered in as timely a fashion as possible. Please utilize our website for making payments and to submit changes to your policy.


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Personal Information
Name of Policyholder First Name:*
  Last Name:*
EMail Address:*
Phone:* (1)
Are you the owner?*
Are you the primary player?*
Customer Type:*
Date of Birth (MM/DD/YYYY):*

OPTIONAL: I wish to authorize another individual on my policy. I understand that this will allow them to request information and make changes on my behalf.

Authorized Individual Name:
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*Contact our office with any questions regarding authorizing someone on your policy.

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Location of Instrument(s)
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Desired Effective Date of Policy
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