Federal Credit Application Insurance Disclosure

I have applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance product or annuity in connection with this extension of credit. FEDERAL LAW PROHIBITS YOU FROM CONDITIONING THE EXTENSION OF CREDIT ON EITHER:

My purchase of an insurance product or annuity from you or from any of your affiliates; or
My agreement not to obtain or a prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity.

I acknowledge that I have received a copy of this form on today’s date or within three (3) days if I have applied by telephone. Unless this disclosure is provided electronically or I have applied for credit by mail, I also acknowledge that you have provided this disclosure to me orally.

220 EAST MAIN STREET, AMBOY, ILLINOIS 61310 | (815) 857-3625 | (815) 857-2341 FAX

DOWNLOAD MOBILE APP

App Store is a service mark of Apple Inc. Android, Google Play, and the Google Play logo are trademarks of Google Inc. Data charges may apply. Check with your mobile phone carrier for details. Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. CardValet is a registered trademark of Fiserv, Inc. or its affiliates.