Fill and Sign the Claim and Authorization Form Claim Customer Information

Authorization for Release of Insurance Information with Regard to Pending Litigation To:____________________________________ (Name of Insurance Company) ________________________________________________________ (Address of Insurance Company) Regarding: __________________________ (Name of Insured) Date of Birth of Insured: _____________________ Social Security Number of Insured: ___________________________ Maiden Name or Alias: _________________________________________________ Policy No: ___________________________________ Claim No: ____________________________ Date of Accident/Incident: ______________________ I, the undersigned ____________________ (Name of Insured) , hereby authorize any insurance entity to release any and all information, including personal injury protection papers, billing records, claims information, disability information, photographs, medical reports, accident investigation reports, incident reports, etc . to: __________________________ (Name of Person or Entity) . This Authorization is for the purpose of copying records. The information being sought is to be used in the evaluation of a pending lawsuit. Failure to authorize the release of this information may cause a delay in processing the lawsuit. A photocopy of this consent is as valid as the original. This authorization is made in accordance with the federal and state law and is valid for a period of 12 months after being signed or at the conclusion of the following: _____________________ ___________________________________________ (Name of Case) Witness my signature this _______________________ (date) . _________________________________ (Printed Name of Insured) _________________________________ (Signature of Insured) SWORN to and subscribed before me, this the ____ day of _____________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________