Insurance Claim Repayment

INSURANCE CLAIM REPAYMENT AGREEMENT

Parties and Claim Identification

Insurer Name:

Date of Birth:     Policy Number:

Claim Number:     Date of Loss:

Amount Paid by Insurer: $     Date Paid to Insured:

Repayment Basis and Selection

This Repayment Agreement documents the obligation of the Applicant to repay all or a portion of the payment referenced above for the following reason(s). Check all that apply:

Overpayment to Insured    Advance Payment Recovery    Deductible Reimbursement

Subrogation Recovery    Fraudulent or Unauthorized Payment    Other:

Repayment Terms

Repayment Amount Owed: $     Payment Method (select one): Lump Sum    Installment Plan

Interest on Outstanding Balance:     Late Fee: $

Payment Authorization

Bank Name:

Account Holder Name:

Routing Number:     Account Number:

Account Type: Checking    Savings

By signing this Agreement the Applicant authorizes the Insurer to initiate debit entries to the account identified above, to effect repayment in accordance with the selected terms, and to apply any collected amounts against the outstanding repayment balance.

Documentation and Attachments

Attachments submitted with this Agreement (check all that apply):

Receipts / Invoices    Correspondence with Insurer    Bank Statements

Representations, Covenants, and Remedies

Applicant represents and warrants that the information provided in this Agreement and in any attachments is true, complete, and correct to the best of Applicant's knowledge. Applicant covenants to repay the amount set forth above in accordance with the terms selected. Applicant acknowledges that failure to timely make payments constitutes default, entitling the Insurer to pursue all available remedies, including acceleration of the outstanding balance, collection costs, reasonable attorney fees, reporting to consumer credit agencies, and pursuit of any contractual or equitable remedies otherwise available.

Upon receipt by the Insurer of full and final payment in cleared funds, the Insurer will execute and deliver a release of the Applicant's repayment obligation for the amounts paid and so indicated. Partial payments do not constitute forgiveness or satisfaction of the repayment obligation unless the Insurer issues a written release signed by an authorized representative.

Exclusions and Limitations

This Agreement does not alter, amend, or waive any other rights or defenses of the Insurer under the policy of insurance, applicable law, or other written agreement, except as expressly set forth herein. The Insurer retains the right to pursue recovery from other responsible parties where applicable, and any amounts recovered by the Insurer from third parties may be credited against the Applicant's repayment obligation in accordance with applicable law and the Insurer's accounting practices.

Certification and Acknowledgment

By signing below, Applicant certifies under penalty of perjury that Applicant is legally obligated to repay the amounts described in this Agreement, that Applicant has had the opportunity to review the Agreement and seek independent advice, and that Applicant authorizes the Insurer to take the collection and payment actions described herein. Applicant further acknowledges receipt of a copy of this executed Agreement.

Sign Now