Claim Document Copy

CLAIM DOCUMENT COPY

Claim Number:   Date of Copy Issued:

Parties and Recitals

Claimant Name:

Custodian / Provider Name:

WHEREAS, Claimant has submitted a claim identified above and has requested copies of claim-related records; and

WHEREAS, Custodian / Provider is the holder of the claim file and related documents and is authorized or required to produce copies in accordance with applicable law and contractual obligations; and

WHEREAS, the parties desire to document the delivery, contents and terms under which this Claim Document Copy is provided.

Scope of Documents Provided

The Provider hereby delivers a copy of the claim file as indicated below. The copy includes documents only as numbered or checked in this form. This copy is provided for the limited purposes stated in the Scope of Documents and is not a waiver of any privilege except to the extent expressly indicated.

Claim Form Proof of Loss Supporting Invoices Photographs

Other Documents (describe):

Total Pages Included:

Scope of Work

The Provider shall prepare and deliver the document copy set forth above in a legible format. This includes redaction where required by law or privilege, indexing of produced pages, and an itemized inventory of documents produced. Any redaction will be documented in the inventory.

Payment Terms

Copy Fee Amount: $   Payment Schedule:

Late Fee:   Interest After (days):

All fees payable under this document are non-refundable except as expressly agreed in writing. If payment is not made when due, Provider may suspend further production until outstanding amounts are paid, and may recover reasonable costs and attorneys' fees incurred in collection.

Term and Termination

Effective Start Date:   Term End Date:

Either party may terminate the provision of additional copies or related services for material breach of these terms by the other party, or for failure to pay fees, upon written notice. Notice Period (days):

Confidentiality

The parties acknowledge that copies of claim files may contain confidential, proprietary, or personally identifiable information. The receiving party shall hold all confidential information in strict confidence, shall not disclose it except as required by law, and shall use it only for the purpose stated in this document. This obligation does not apply to information that is or becomes public through no fault of the receiving party, or that was already rightfully known to the receiving party prior to disclosure.

The confidentiality obligations set forth herein shall survive termination or expiration of this Claim Document Copy for a period of unless a longer period is required by law.

Governing Law

This document and any disputes arising under or in connection with it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

Entire Agreement

This Claim Document Copy, including the inventory and any written attachments signed by the parties, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior or contemporaneous agreements, understandings, representations and warranties, whether written or oral.

Certification of Copy

I certify that the copy provided hereunder is, to the best of my knowledge and based upon a reasonable review, a true and complete reproduction of the original claim documents in the custody of the Provider except where specific redactions or omissions are noted in the attached inventory.

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