Enrollment Form
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\r\n(Electronic Consent to Electronic Receipt of Electronic Record and Signature Disclosures)
\r\nFrom time to time, Gallagher (we, us or Gallagher) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the website where this document is linked. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by selecting the “Opt-In for eDelivery of Policy Documents” and/or the “Go Paperless for My Billing Invoices” radio buttons from the link provided on your Member Service Portal Account page.
\r\nAt any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You may request delivery of such paper copies from us by following the procedure described below.
\r\nYou may at any time withdraw your consent to receive notices and disclosures from us electronically, and request that thereafter you want to receive required notices and disclosures only in paper format by providing notice as described below.
\r\nIt will take significantly longer for us to deliver notices and disclosures in paper format. However, if you still desire to withdraw your consent, you must do so by emailing Gallagher at
Unless you inform us of your intent to withdraw consent per the email process specified above, we will provide electronically to you by email or through the website all required notices, disclosures, authorizations, acknowledgements and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below.
\r\nYou may contact us to let us know of your changes as to (i) how we may contact you electronically (including any changes in your email address where we should send notices and disclosures electronically to you), (ii) to request paper copies of certain information from us, and (iii) to withdraw your prior consent to receive notices and disclosures electronically as follows:
\r\nTo contact us by email, please send messages to:
For paper copies of documents, please provide the following information in any email communications: email address, full name, US Postal address, and telephone number.
\r\nTo confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure and that you also were able to print on paper or electronically save this page for your future reference and access or that you were able to email this disclosure and consent to an address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format on the terms and conditions described above, please confirm by selecting the “Opt-In for eDelivery of Policy Documents” and/or the “Go Paperless for My Billing Invoices” radio buttons from the link provided on your Member Service Portal Account page.
\r\nBy opting-in to eDelivery and Going Paperless, I confirm that:
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