Insurance Assistance Program

INSURANCE ASSISTANCE PROGRAM

This Insurance Assistance Program application requests information necessary to determine eligibility for financial or administrative assistance related to an existing insurance policy or an eligible claim. Completion of this form authorizes inquiry and verification of information as described in the Authorization and Certification section below.

Applicant / Insured Information

Policy / Coverage Information

Assistance Requested

Please indicate the type(s) of assistance requested (select all that apply):

Coverage Details

Coverage elements present on the policy (select all that apply). If applicable, provide policy limits or notes in the Description box.

Documentation Checklist

Submit copies of the following documents where applicable. Check items included with this application.

Loss / Claim Summary (if applicable)

Financial & Household Information

Beneficiary Designation (for assistance disbursement)

Identify one or more payees to receive assistance funds on your behalf. Total percentage allocation must equal 100%.

Exclusions & Limitations

Assistance provided under this program is limited and subject to the following exclusions: assistance will not cover losses resulting from willful misconduct, criminal activity, fraud, intentional misrepresentation, or losses excluded by the governing insurance policy. Assistance does not establish coverage where coverage is otherwise excluded by the insurer. The program does not guarantee claim approval by the insurer.

Any assistance amount paid is subject to audit and may be recovered in the event of ineligibility, misrepresentation, overpayment, or subsequent recovery from other sources including subrogation or third-party recovery.

Authorization and Certification

By signing below, the Applicant certifies under penalty of perjury that the information provided in this application and all supporting documentation is true, complete, and accurate to the best of the Applicant's knowledge. The Applicant authorizes program administrators, insurers, and their agents to verify any information provided, to obtain relevant policy, claims, income, or medical records, and to disclose information to third parties for purposes of processing this application, conducting audits, and enforcing recovery rights.

The Applicant acknowledges that provision of assistance may require repayment or offset against future benefits if documentation reveals ineligibility, misstatement, or if recovery is obtained from third parties. The Applicant agrees to cooperate with reasonable post-payment audits and to execute documents necessary to effectuate recoupment or subrogation when requested.

The Applicant understands that approval is discretionary and may be conditioned upon available program funds, insurer requirements, and verification of eligibility. The program reserves the right to deny, reduce, or terminate assistance at any time for cause.

Program Terms and Governing Provisions

Assistance granted under this application creates a limited contractual obligation of the program only as to the specific assistance described in any written award notice. The Applicant agrees to the program's right to recover amounts paid through setoff, direct demand, placement of liens where permitted, or referral for collection. The program's liability is limited to payments expressly authorized in writing. This application and any assistance award shall be governed by applicable law and construed consistent with the purpose of the program.

Applicant Certification and Signature

I certify that I am the Applicant named in this form, that I have the authority to request assistance for the named policy or claim, and that I understand and accept the terms set forth in this application. I understand that false statements or material omissions may result in denial of assistance and may subject me to civil or criminal penalties.

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