Insurance Compensation Documents

INSURANCE COMPENSATION DOCUMENTS

1. Insured / Applicant Information

2. Policy Details

Policy Type (select all that apply):

Auto    Property    Liability    Professional    Life    Other:

Policy Period: From through

3. Claim / Compensation Request

Date of Loss:    Time of Loss:

Type of Loss (select all that apply): Collision    Theft    Fire    Water    Other

4. Itemized Loss Schedule

Provide an itemized list of damaged or lost property, services, or expenses. Attach supporting documentation for each item.

5. Documentation Checklist

The following documents are submitted with this claim (check all that apply):

Police or incident report    Photographs of loss/damage    Repair / replacement estimates    Receipts / invoices    Medical reports / bills    Other documents:

6. Coverage Selection for Compensation

Requested compensation under applicable coverage:

Repair cost    Replacement cost    Actual cash value (ACV)    Medical expense reimbursement    Loss of income    Funeral expense

7. Exclusions, Reductions and Subrogation

The undersigned acknowledges that compensation will be subject to the terms, conditions, exclusions and limitations of the policy. The following exclusions commonly apply and may reduce or deny payment where applicable:

1. Loss caused by intentional acts, fraudulent misrepresentations, or criminal conduct; 2. Wear and tear, gradual deterioration, or inherent vice; 3. Economic losses not covered by the specified coverage form; 4. Losses excluded by endorsement or prior written notice; 5. Governmental seizure or regulatory actions. This list is illustrative and not exhaustive.

Subrogation and Recovery: The insurer may seek recovery from third parties responsible for the loss. The insured agrees to cooperate in the insurer's subrogation efforts and to execute instruments necessary to secure recovery rights.

I acknowledge that I have read and understand the foregoing exclusions and subrogation provisions: Acknowledged

8. Payee / Beneficiary Information

9. Release, Certification and Authorization

Release and Final Settlement: In consideration of payment by the insurer of the compensation requested and approved under this claim, the undersigned agrees that any payment made in full or partial settlement of this claim shall constitute full and final settlement of all claims arising from the described loss, to the extent of the payment, unless otherwise expressly reserved in writing by the insurer. Upon acceptance of payment the undersigned releases the insurer, its agents and representatives from further liability for the matters described in this claim, except for any obligations expressly set forth in the insurer's written settlement agreement.

Certification: I certify under penalty of law that the information provided in this document and any attachments is true, complete and accurate to the best of my knowledge. I understand that material misrepresentation, omission or fraud in connection with this claim may result in denial of benefits, rescission of coverage, recovery of payments made, and may subject me to civil or criminal penalties.

Authorization: I authorize the release of pertinent medical, repair, employment, and other records necessary to adjudicate this claim. I agree to cooperate with the insurer's investigation, to provide truthful statements, and to execute additional documents required to process payments or perfect subrogation and recovery rights.

Fraud Notice: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties as provided by law.

By signing below, the undersigned certifies that they are authorized to submit this claim and accept the terms of this document on the insured's behalf where applicable.

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