Bad Faith Authorization Form

Bad Faith Authorization Form

This Bad Faith Authorization Form (the Authorization) is entered into by and between Claimant Name: (the Claimant) and Authorized Representative Name: . Effective Date: .

Recitals

WHEREAS, the Claimant is or was insured under one or more insurance policies issued by one or more insurers identified below and has experienced claim handling, adjustment, denial, delay or other conduct by an insurer that the Claimant believes may constitute bad faith; and

WHEREAS, the Claimant has retained the Authorized Representative to evaluate, pursue, and, if appropriate, prosecute claims and remedies against insurers for bad faith, statutory penalties, and related relief; and

WHEREAS, the Claimant wishes to authorize the Authorized Representative to obtain documents and communications, to waive certain confidentiality to the extent necessary for representation, and to pursue administrative or judicial remedies on the Claimant's behalf.

Now, Therefore

In consideration of the mutual covenants set forth herein, the parties agree as follows:

1. Definitions

"Claim File" means all documents, notes, memoranda, electronic files, photographs, recorded statements, surveillance materials, and other records maintained by or on behalf of any insurer, adjuster, attorney, or third party that relate to the claim(s) identified in this Authorization.

2. Insurer and Claim Identification

3. Authorization to Obtain Records

The Claimant hereby authorizes and directs any insurer, claims administrator, adjuster, third-party administrator, medical provider, employer, and other custodian of records to release and deliver to the Authorized Representative, upon request, complete copies of the Claim File and all records related to investigation, evaluation, handling, adjustment, reservation of rights, communications, and litigation concerning the claim(s) referenced above.

Claim file and notes
Internal and external communications (email, memos, correspondence)
Medical records and reports
Surveillance and investigative reports
Reserve and claim valuation documents

4. Scope and Limitations

This Authorization includes electronic records and metadata, drafts and final documents, and records created before, during, or after the date of loss. Notwithstanding the foregoing, this Authorization does not authorize the Representative to settle or compromise the Claimant's underlying claim without express written consent from the Claimant or to waive the Claimant's attorney-client privilege except to the extent necessary for the prosecution of bad faith claims and only as authorized by the Claimant in writing.

5. Waiver and Disclosure

The Claimant knowingly and voluntarily authorizes the disclosure of protected information to the Authorized Representative for the purpose of investigating and pursuing claims for bad faith, statutory penalties, and related relief. The Claimant expressly authorizes disclosure to experts, consultants, and opposing counsel as necessary in furtherance of such representation, subject to applicable privilege rules and as ordered by a tribunal where required.

6. Fees, Costs, and Assignment

The Claimant authorizes payment or allocation of any recovery for bad faith, including attorneys' fees and costs, as agreed in the representation agreement between the Claimant and the Authorized Representative. The Claimant may separately designate whether recovered fees may be applied to outstanding liens, subrogation claims, or expenses by listing such obligations below.

7. Term and Revocation

This Authorization remains in effect until revoked in writing by the Claimant, provided that revocation will not affect disclosures already made in reliance on the Authorization. Revocation must be sent to the Representative and to any custodians of records at the addresses provided in Section 9.

8. Limitation of Liability and Indemnity

The Authorized Representative will exercise reasonable care in handling all records and information. The Claimant releases the Representative from liability for actions taken in good faith under this Authorization and agrees to indemnify the Representative against claims arising from the Claimant's misrepresentations or from disclosures expressly authorized herein, except to the extent caused by the Representative's gross negligence or willful misconduct.

9. Notices

Any notice required or permitted under this Authorization shall be made in writing and delivered to the addresses provided below by hand, certified mail, or overnight courier. Notice is effective upon receipt.

10. Governing Law

This Authorization shall be governed by and construed in accordance with the laws of the jurisdiction selected by the Claimant below, without regard to conflict of law principles.

11. Entire Agreement; Severability; Amendments

This Authorization constitutes the entire agreement between the parties relating to the subject matter hereof and supersedes prior oral or written statements regarding authorization to obtain records for the purposes described herein. If any provision of this Authorization is held invalid or unenforceable, the remaining provisions will remain in full force and effect. This Authorization may be amended only by a writing signed by both parties.

12. Counterparts

This Authorization may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

13. Additional Representations

The Claimant represents and warrants that the Claimant is authorized to execute this Authorization, that the information provided herein is true and correct to the best of the Claimant's knowledge, and that no other person or entity has a superior right to the records requested except as disclosed in Section 6.

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