Insurance Auto Consent Form

INSURANCE AUTO CONSENT FORM

The undersigned insured or applicant (hereafter "Insured") furnishes the information below and grants the authorizations and consents set forth in this Insurance Auto Consent Form to the insurer, its agents, representatives, adjusters, repair facilities, and their authorized designees for purposes related to underwriting, claims handling, loss adjustment, payment, recovery and fraud prevention.

INSURED / APPLICANT INFORMATION

Insured Name:

Date of Birth:    Phone:    Email:

Driver's License No.:    State of Issue:

VEHICLE INFORMATION

Year:    Make:    Model:

Vehicle Identification Number (VIN):

License Plate:    Registration State:

POLICY DETAILS

Insurer Name:

Policy Number:    Policy Type: Liability Collision Comprehensive

Coverage Limit:    Deductible:    Premium:

Policy Period From:    To:

COVERAGE AND AUTHORIZATIONS

Select coverages applicable to this policy and consent to related actions:

Liability Coverage    Collision Coverage    Comprehensive Coverage

Uninsured/Underinsured Motorist Coverage    Medical Payments Coverage

CONSENT TO OBTAIN RECORDS & RELEASE OF INFORMATION

I authorize and consent to the insurer, its representatives, contracted vendors and agents to obtain, review and exchange with third parties any records and information reasonably related to the procurement, underwriting, investigation and adjustment of claims arising from the motor vehicle identified above. This includes, without limitation, motor vehicle records, claims history, repair estimates, photographs, surveillance, medical records and billing, and vehicle inspection reports. This authorization includes release of records by medical providers, repair facilities, law enforcement, employers, and other insurers.

I understand that information obtained pursuant to this authorization may be shared with reinsurers, claims administrators and attorneys for the purpose of claim handling, subrogation, litigation, fraud investigation and regulatory compliance. I further acknowledge that a photocopy or electronically transmitted copy of this authorization is as valid as the original.

INSPECTION, APPRAISAL AND REPAIR AUTHORIZATION

I authorize the insurer, its adjusters, appraisers and authorized repair facilities to inspect, tow, appraise, repair and/or estimate repair costs for the vehicle described above. I consent to rendering the vehicle available for inspection and to the release of keys, title documents, and possession as reasonably necessary to effectuate inspection, repair, or salvage dispositions. I understand that authorization to inspect or repair does not create an obligation on the part of the insurer to pay beyond policy limits or for work not previously approved where required.

ASSIGNMENT OF BENEFITS / PAYMENT AUTHORIZATION

I authorize the insurer, at its discretion, to pay or direct payment of repair estimates, approved repairs and covered medical expenses to the repair facility or medical provider identified by me or by the insurer. This authorization is limited to amounts the insurer determines are due and payable under the policy. I understand that assignment of benefits does not alter my obligations under the policy, including the duty to pay uncovered charges and applicable deductibles.

ELECTRONIC COMMUNICATIONS AND RECORDS

I consent to receive communications, notices and disclosures related to my policy and claims electronically by email, text message or other electronic means. I understand that my consent may be withdrawn in writing, but withdrawals will not affect prior communications made in reliance upon this consent.

EXCLUSIONS AND LIMITATIONS

This Consent does not authorize disclosure of psychotherapy notes or other records protected by law without additional required consent. This Consent is limited to information reasonably related to the matters described above. The insurer's receipt or use of information obtained pursuant to this Consent shall be subject to applicable privacy and data security laws. This Consent does not waive any rights or defenses under the policy.

BENEFICIARY DESIGNATION (IF APPLICABLE)

If the policy provides benefits payable to a beneficiary (for example, accidental death or medical payment benefits), designate beneficiary(ies) below. If more than one beneficiary is named, indicate the percentage of benefit for each. If no beneficiary is designated, statutory default provisions will apply.

Relationship:    Percentage:

DOCUMENTATION CHECKLIST (ATTACH IF AVAILABLE)

Copy of Driver's License    Vehicle Registration    Photographs of Loss

CERTIFICATION AND ACKNOWLEDGMENT

I certify under penalty of perjury that the information provided in this form is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of material facts may be grounds for denial of coverage or rescission of the policy to the fullest extent permitted by law. I further acknowledge that I have read and understand the consents above and that this authorization shall remain in effect for the period necessary to process the applicable claim or policy transaction, unless earlier revoked in writing.

Sign Now