PermaSafe’s Online Registration

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    Customer Contact Information

    Note: An accurate email address is required to deliver and receive benefit information.

    Vehicle Information

    Electronic Consent

    By electronically signing below, I hereby certify the above information to be true and correct to the best of my knowledge. I further certify that my electronic signature shall have the same legal effect as an originally signed document under applicable Federal and Florida electronic signature laws.

    Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.