Insurance Claim Agreement

Insurance Claim Agreement

This Insurance Claim Agreement ("Agreement") is entered into between Insurer Name: and Claimant / Insured Name: effective as of Date:

Insured / Claimant Information

Policy Details

Claim Details

Date of loss:    Time of loss:

Supporting Documentation (Check all that apply)

Police report

Photographs of damage / scene

Repair estimates / invoices

Medical records / bills

Receipts for replaced items

Coverage & Exclusions

Applicable coverages claimed (check all that apply):

Property damage

Bodily injury

Collision

Comprehensive

Liability

Exclusions and limitations (the claim and any payment are subject to policy terms, conditions, limitations and exclusions, including but not limited to: wear and tear, intentional acts, fraud, business interruption not covered by the policy, pre-existing damage, war and nuclear perils where excluded). Claimant acknowledges that payment is limited to covered loss under the policy and does not extend coverage beyond policy limits.

Claimant acknowledges receipt of a copy of the applicable policy provisions upon request and understands that evaluation and payment, if any, will be made in accordance with the policy terms, subject to deductible and policy limits.

Assignment, Subrogation and Authorization

Assignment of benefits: Claimant hereby authorizes assignment of benefits to repairers or medical providers if electing direct payment, contingent upon insurer's written consent. To effectuate assignment, claimant affirms that any such assignment will not increase insurer liability beyond policy limits.

Subrogation: Claimant agrees to cooperate with insurer in the pursuit of subrogation rights and hereby assigns to insurer any and all rights of recovery against third parties to the extent of any payment made by insurer under the policy. Claimant will not release any third party or sign any settlement that would prejudice insurer's subrogation rights without insurer's prior written consent.

Authorization to obtain records: Claimant authorizes insurer, its agents or representatives to obtain and review records, invoices, bills, medical records, police reports and other documents reasonably related to this claim. Claimant also authorizes providers to release such records to insurer for the purpose of claim investigation and adjustment.

Claims Certification and Fraud Warning

Certification: By signing below, claimant certifies under penalty of perjury that the information contained in this claim and any supporting documentation is true, correct and complete to the best of claimant's knowledge. Claimant agrees to promptly notify insurer of any change in circumstances affecting this claim.

Fraud warning: Claimant acknowledges that knowingly presenting false or fraudulent information or concealing material facts in support of a claim may constitute insurance fraud and may result in denial of benefits, policy cancellation, criminal prosecution and civil liability.

Beneficiary / Payee Information (if different)

Indemnity, Reimbursement and Governing Law

Indemnity and reimbursement: If insurer pays amounts under this claim and later determines that payment was not owed due to error, misrepresentation, or later recovery from a third party, claimant agrees to reimburse insurer for such amounts and to cooperate in recovery efforts. Insurer may offset future benefits against amounts owed by claimant to insurer under this Agreement.

Governing law and venue: This Agreement shall be governed by the laws of the state identified below, without regard to choice-of-law rules. Claimant consents to the exclusive jurisdiction and venue of courts located in the governing state for disputes arising directly from this Agreement.

Final Acknowledgment

By signing this Agreement, claimant acknowledges that claimant has read and understands the policy terms relevant to this claim and the statements contained in this Agreement. Claimant authorizes insurer to investigate and evaluate the claim, to obtain records, and to take actions reasonably necessary to adjust and, if appropriate, settle the claim consistent with the policy.

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