Insurance AOR and BOR Form

INSURANCE AOR AND BOR FORM

1. Insured / Applicant Information

Date of Birth:    Telephone:    Email:

2. Policy Details

Policy Type:    Coverage Limit:

Deductible:    Premium:

Policy Period From: to

3. Coverage Selections

Please indicate the coverages applicable under the referenced policy (check all that apply):

General Liability    Property Damage    Automobile Liability    Medical Payments

Uninsured/Underinsured Motorist    Collision    Comprehensive    Business Interruption

4. Exclusions

The following exclusions apply to any assignment of rights and benefit recovery under this form. If an exclusion below is not applicable, mark N/A and provide explanation.

5. Beneficiary of Record (BOR) Designation

Designate the person or entity to receive any net recoveries after payment of expenses and advances related to recovery efforts.

Relationship to Insured:    Allocation Percentage: %

6. Assignment of Rights (AOR)

Effective as of: , the Insured hereby grants, assigns, and transfers to the Insurer all rights, causes of action, claims, demands, and proceeds (collectively "Assigned Rights") arising from any loss for which the Insurer has paid or may pay under the policy identified above. This Assignment of Rights is made for the purpose of enabling the Insurer to pursue recovery, compromise, and enforce remedies against liable third parties.

The Insured authorizes the Insurer to exercise all reasonable rights of subrogation, including the prosecution, settlement, and dismissal of claims, and to retain counsel and incur expenses to recover amounts paid under the policy. Recovered amounts shall be applied first to reimburse the Insurer for paid losses, expenses of recovery, and legal fees; any remaining balance shall be distributed to the Beneficiary of Record in accordance with the BOR designation.

Limited Assignment Option: Full Assignment    Limited Assignment (specify limitations below)

7. Cooperation and Representations

The Insured agrees to cooperate fully with the Insurer in all recovery efforts, including providing truthful statements, executing documents, providing access to records, and attending legal proceedings when reasonably requested. The Insured represents that the information provided in this form is true and correct to the best of the Insured's knowledge and that no other assignment of the same rights has been made except as disclosed herein.

The Insured acknowledges that any recovery collected on Assigned Rights shall first reimburse the Insurer for payments made, costs and expenses of recovery, and attorney fees, and that the Insurer's rights are subject to any priority liens or subrogation agreements of record at the time of recovery.

8. Allocation and Distribution of Recoveries

Specify how recovered funds should be applied and distributed after payment of recovery expenses and Insurer reimbursement.

9. Acknowledgements, Indemnity and Governing Law

The Insured acknowledges that the Insurer may incur costs in pursuing recoveries and that the Insurer may deduct such costs and reasonable attorney fees from recovered sums. The Insured hereby agrees to indemnify and hold harmless the Insurer for liability arising from the Insured's intentional misrepresentation in connection with this Assignment and BOR designation. This form shall be governed by the laws of the jurisdiction in which the policy was issued, without regard to conflict of law principles.

Notice: Any recovery distributed to a Beneficiary of Record may be subject to tax reporting requirements. The Insurer makes no warranty as to tax consequences and recommends that the Insured seek tax advice if necessary.

10. Additional Documentation

Attach supporting documentation as necessary (copies of policy declarations, proof of loss, proof of payment, prior assignments). Check items attached:

Policy Declarations    Proof of Loss    Receipts / Bills    Other (describe below)

11. Certification

By signing below, the Insured certifies under penalty of perjury that the information provided is accurate and complete. The Insured authorizes the Insurer to rely upon this form as the exclusive Assignment of Rights and Beneficiary of Record designation with respect to the policy and matters described herein unless an express written revocation is delivered to the Insurer in accordance with applicable policy terms.

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