Insurance AOR WC Form

Authorization of Representation and Assignment of Rights — Workers' Compensation (AOR WC)

Applicant / Injured Worker Information

Date of Birth: Phone: Email:

Employer and Policy Details

Policy Type: Workers' Compensation Employers' Liability

Policy Period: From to

Coverage Limit: Deductible: Premium:

Coverage Selections and Acknowledgement

Please indicate coverages applicable to this claim or policy:

Medical Benefits
Wage Replacement / Temporary Disability
Permanent Disability Benefits
Death Benefits
Vocational Rehabilitation

Exclusions (Acknowledgement)

The undersigned acknowledges that coverage may be subject to policy exclusions. Check acknowledgement:

Pre-existing condition exclusion may apply
Intentional or self-inflicted injuries excluded
Non-work-related injuries not covered
Injuries while under influence of controlled substances may be excluded

Claim Information and Assignment of Recovery

Date of Injury:

Was a third party involved in the incident? Yes No

Estimated Economic Loss / Damages: $

Authorization and Assignment (Legal Terms)

I, the undersigned Applicant, hereby appoint and authorize the Insurer, its designated claims representatives, and any attorney retained by the Insurer to take any and all actions reasonably necessary to pursue recovery, subrogation, or reimbursement from any third party or their insurer for benefits paid or payable on account of the injury identified above. This authorization includes, but is not limited to, the right to:

1. Obtain and inspect all medical records, billing statements, employment and wage records, and other documents relevant to the claim;
2. Initiate and prosecute claims, suits, or administrative actions against third parties, including settlement negotiations and entry into compromise agreements;
3. Receive and apply recovered funds to reimburse the Insurer for benefits and expenses paid, including costs of investigation and litigation;
4. Execute releases, settlement agreements, subrogation assignments, or other instruments necessary to effectuate recovery, subject to the approval requirements set forth below.

Assignment of Recovery: I assign to the Insurer any right of action or claim I possess against any third party to the extent of benefits paid or to be paid by the Insurer arising out of the injury described herein. I acknowledge that recoveries obtained after payment of costs and attorney fees will be used first to reimburse the Insurer for benefits paid and associated expenses.

Settlement Approval: The Insurer shall not compromise or settle any recovery action that would adversely affect my statutory workers' compensation entitlement without first providing written notice and an opportunity to approve any settlement allocation concerning my benefits. Any settlement of a third-party claim that reduces or eliminates the Insurer's right of reimbursement shall require my cooperation in signing necessary documents to protect the Insurer's interests.

Documentation Checklist

Please indicate documents attached or to be provided in support of this authorization:

Medical records and bills
Wage and payroll records
Witness statements
Photographs or physical evidence
Police or incident report

Beneficiary Designation (Death Benefits)

If death benefits are payable under the policy, designate primary beneficiary:

Relationship: Allocation Percentage: %

Certification and Signature

Certification: I certify under penalty of law that the information provided in this Authorization of Representation and Assignment of Rights is true, complete, and accurate to the best of my knowledge. I understand that this authorization remains in effect until revoked in writing, and that any revocation will not affect actions taken by the Insurer in reliance on this authorization prior to receipt of written revocation. I further acknowledge that I have read and understand the Assignment of Recovery provisions above and that I will cooperate with the Insurer in pursuing subrogation or third-party recovery actions, including providing documentation and execution of necessary instruments.

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