Insurance Claim Payout

INSURANCE CLAIM PAYOUT AUTHORIZATION

Insurer and Claim Identifiers

Insurer Name:

Policy Number:    Claim Number:

Claims Adjuster:    Adjuster Contact:

Insured / Payee Information

Claim Details

Date of Loss:    Time of Loss (if known):

Coverage and Payout Summary

Applicable Coverages (check all that apply):

Property / Dwelling    Personal Property    Liability    Additional Living Expense

Gross Allowed Amount: $

Deductible: $    Prior Payments / Recoveries: $

Tax Withheld (if applicable): $    Net Payable Amount: $

Payment Instructions and Payee Designation

Payment Method (select one):

Mail check to insured address    Direct deposit (ACH) to bank account below    Issue to third-party payee (enter payee information)

Account Holder:    Account Number:

Routing Number:    Account Type: Checking    Savings

Documentation Checklist

Required documentation submitted with this payout authorization (check all that apply):

Police report    Photographs of loss    Repair estimate / contractor invoice    Receipts for replaced items

Exclusions, Release, and Subrogation

By signing below, the insured authorizes the insurer to issue payment in the net amount indicated above to the designated payee. Receipt of the net payout constitutes a full and final settlement by the insurer for the items specifically identified in the payout calculation and releases the insurer from any further obligation with respect to those items, subject to the insurer's right of recovery as set forth below.

The insured acknowledges that payment does not expand coverage beyond the terms of the policy and that the following standard exclusions remain applicable unless expressly stated otherwise: wear and tear, latent defects, intentional acts, consequential damages, and losses excluded by the policy terms. The insured further agrees that any payment made to a mortgagee, lienholder, or other third party will be applied to the insured interest and that the insurer may endorse documents as necessary to effect payment.

Subrogation and Overpayment Recovery: The insurer retains all subrogation rights against responsible third parties. The insured agrees to cooperate fully with insurer subrogation efforts. If the insurer recovers amounts for which payment has been made, or if an overpayment is determined, the insurer reserves the right to recover any overpaid amounts from the insured or payee.

Certification and Authorization

I certify that the information provided in this authorization is true and accurate to the best of my knowledge. I authorize the insurer to issue the payment as indicated and, if necessary, to deposit funds electronically to the bank account identified above. I further authorize the insurer to endorse any instrument on my behalf for the limited purpose of delivering payment when required by contractual or lienholder arrangements. I understand that false statements made in connection with this claim may be subject to denial of benefits and legal penalties.

Acknowledgment of Understanding

I acknowledge that I have read and understand the settlement terms above and that by signing I accept the net payment as full settlement for the items described in this document unless otherwise specified in writing by the insurer.

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