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My ID Fix™,
Inc. Identity Theft Insurance
© with the My ID Fix ™, Inc. Identity Theft Prevention
and/or Credit Monitoring Program
TO PRINT THIS PAGE USE THE CONTROL - ALT - PRINT
SCREEN KEYS. AFTER FILLING IN THE BLANKS AND SIGNING PLEASE FAX
TO 1-760-744-9454 (call first).
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__________________________
Date
_____________________________________________
Authorized Representative
of Purchasing Company
_____________________________________________
Legal Name of Purchasing Company
__________________________
Date
_______________________________________
Authorized Representative of MY ID FIX™, INC.
ORDER FORM
We, the undersigned company are hereby purchasing
the MY ID FIX™, INC.:
___(place check mark here) Corporate Identity Theft
Prevention
and Identity Theft Insurance for __________ employees
and/or
clients at a price of _________ per employee and/or
client per
month for one year. The total annual premium is
__________
payable in advance. We understand that we will receive
a MY ID
FIX™, INC. Identity
Theft Insurance policy with Aggregate Limit of
Insurance: $ _______ per policy period, and with
Lost Wages:
$ _______ per week, for 4 weeks maximum, and with
a Deductible
$ _______ per policy period underwritten by AIG
and will receive
the MY ID FIX™, INC.
Identity Theft Prevention program.
-or-
___ (place check mark here) Corporate Credit Monitoring
Program
and Identity Theft Insurance for __________ employees
and/or
clients at a price of _________ per employee and/or
client per
month for one year. The total annual premium is
__________
payable in advance. We understand that we will receive
a MY ID
FIX™, INC. Identity
Theft Insurance policy with Aggregate Limit of
Insurance: $ _______ per policy period, and with
Lost Wages:
$ _______ per week, for 4 weeks maximum, and with
a Deductible
$ _______ per policy period underwritten by AIG
and will receive
the MY ID FIX™, INC.
Credit Monitoring program.
Date
_____________________________________________
Authorized Representative
of Purchasing Company
_____________________________________________
Legal Name of Purchasing Company
__________________________
Date
_______________________________________
Authorized Representative of MY ID FIX™, INC.
TO PRINT THIS PAGE USE THE CONTROL - ALT - PRINT
SCREEN KEYS. AFTER FILLING IN THE BLANKS AND SIGNING PLEASE FAX
TO 1-760-744-9454.
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