Insurance Claims Handling Authority

INSURANCE CLAIMS HANDLING AUTHORITY

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Policy Details

Policy Type: Liability Property Automobile Umbrella Workers' Compensation Professional Liability

Policy Period Start:   End:

Claims Authority — Appointment

I, the undersigned Applicant / Insured, hereby designate and appoint the following person or entity as my authorized Claims Representative to act on my behalf with respect to the Claim(s) described in this instrument. This appointment authorizes the Representative to act in my stead to the extent set forth below.

Scope of Authority

The Representative is authorized to perform the following acts on my behalf as they relate to the claim(s) covered by the policy referenced above. Check each authority granted:

Investigate and obtain information and documents related to the loss
Prepare, execute and submit claim forms and notices
Negotiate with insurer(s), adjusters, or third parties
Settle claims and execute releases up to the limit specified below
Receive and endorse claim payments or draft(s) on my behalf
Access my policy, claims, medical, repair and other records necessary to process the claim
Retain adjusters, experts, contractors or legal counsel as necessary
Initiate and prosecute subrogation or recovery actions
Other (describe):

Claims Information (Subject Claim)

Date of Loss:   Time:

Police Report Filed: Yes No   Report Number:

Documentation Checklist

The Representative is authorized to obtain and submit the following documentation as part of claim handling. Check items provided or to be obtained:

Photographs of damage
Receipts, invoices or bills
Repair estimates or appraisals
Medical records and bills
Witness statements
Police or official reports
Other (specify):

Exclusions and Limitations

The Representative shall not bind coverage, alter policy terms, or waive coverage defenses on my behalf. The following standard exclusions apply to this authority unless expressly waived in writing:

• Claims arising from intentional acts or fraud by the Insured;
• Claims excluded by the policy terms or endorsements;
• Claims subject to criminal prosecution or exclusive statutory procedures;
• Payment or settlement in excess of the specified monetary limit without prior written consent of the Insured.

Beneficiary Information (If Applicable to Proceeds)

Beneficiary Name:   Relationship:   Share Percentage:

Additional Beneficiary Name:   Relationship:   Share Percentage:

Declarations, Warranties and Indemnity

By executing this Insurance Claims Handling Authority, I represent and warrant that I am the named Insured or authorized representative of the named Insured and that the information provided is true and complete to the best of my knowledge. I authorize the Representative to act within the scope set forth above. I understand that the Representative's authority does not modify my insurance policy or expand coverage beyond the terms and conditions of the policy.

I agree to indemnify and hold harmless the Representative for acts taken in good faith pursuant to this authority, provided such acts are within the scope authorized herein. I acknowledge that the Representative shall not be liable for any loss resulting from my failure to disclose material facts or from acts beyond the scope of authority granted.

This authorization is revocable by me upon written notice to the Representative, but revocation shall not affect any actions taken by the Representative in reliance on this authority prior to receipt of such notice. This instrument shall be governed by the laws of the state identified in my mailing address, without regard to conflict of law principles.

Acknowledgment

I acknowledge that I have read and understand this Insurance Claims Handling Authority. I confirm that I have the legal capacity to grant this authority and that no bankruptcy, insolvency or other legal process prevents the Representative from acting on my behalf with respect to the claims identified herein.

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