Identity Theft Protection Enrollment

Subscriber's Information

First Name This field is required

Last Name This field is required

Address This field is required

City This field is required

State This field is required

Zip This field is required

Home Phone This field is required

Work Phone This field is required

Cell Phone This field is required

Email This field is required

Subscriber's Identification

Account Number This field is required

Last 4 digits of your SSN This field is required

Service Requested

ID Protect Plus (Individual Account)- $7.95 Monthly

ID Protect (Individual Account) - $4.95 Monthly

ID Restoration (Individual Account) - $4.25 Monthly

How did you hear about this product? Choose One Letter in Mail Social Media Farmers State Bank Employee Website Friend/Family Other This field is required

Employee Referred By (if applicable): This field is required

Agreement & Signature

I choose to enroll in the Deluxe Provent service package selected above and authorize the monthly fee to be automatically deducted from my checking account listed above. I authorize Farmers State Bank to provide limited personal information to Deluxe Provent in order for me to receive the benefits of this service package. I understand that I will be receiving email communications from Deluxe Provent regarding my service. I understand to fully receive full benefits of my service package selected above, I am required to activate my online dashboard as provided to me in an enrollment email. If at any time I wish to cancel this service, I will provide notification to the bank either in person, by phone or through an online cancellation form. By initialing this agreement, I authorize a Farmers State Bank representative to activate the service I have selected above and for the monthly fee to be automatically deducted from my Farmers State Bank account.

Initials This field is required