Insurance Letter of Authorization for AOB

INSURANCE LETTER OF AUTHORIZATION — ASSIGNMENT OF BENEFITS (AOB)

Date:    Claim Number:    Policy Number:

Insured / Applicant Information

Policy Period: From to

Loss / Claim Information

Authorized Payee / Provider Information

Phone:    Email:

Assignment of Benefits — Authorization

I, the undersigned Insured, hereby assign and transfer to the named Provider all rights to benefits and proceeds payable under the above-referenced insurance policy(ies) arising from the referenced loss. This Assignment of Benefits authorizes the Insurer to make payment directly to the Provider for covered services and repairs in accordance with policy terms. The assignment includes the right to endorse and negotiate insurance checks, submit and pursue claims, and to take any administrative action necessary to secure payment on my behalf, subject to the limitations set forth below.

By signing below, I authorize the Insurer to release to the Provider any and all information, records, estimates, invoices, and documentation regarding the claim that the Provider reasonably requests for the purpose of processing and collecting assigned benefits.

Scope of Authorization (select applicable)

  Assign all insurance benefits and payments for the above claim to the Provider.
  Limited assignment only for specific services described in itemized estimate below.
  Authorize Provider to file, adjust, and pursue the claim on my behalf.
  Authorize Provider to receive direct payment from Insurer for covered amounts.

Coverage / Claim Details (check all that apply)

  Property Damage     Structure     Contents     Loss of Use     Medical Payments

Documentation Attached (check all that are included)

  Photographs of loss/damage
  Itemized repair estimate/invoice
  Police or incident report
  Medical bills and reports (if applicable)

Exclusions, Limitations and Important Notices

This Assignment of Benefits does not: (a) expand, alter, or change any term, condition, exclusion, or deductible of the insurance policy; (b) transfer ownership of the policy or the right of the Insurer to contest coverage; or (c) permit the Provider to recover amounts in excess of the benefits otherwise payable under the policy. All payments remain subject to the policy terms, conditions, limits, and any applicable coinsurance or deductible.

The Insured acknowledges that the Insurer may require additional documentation or verification and may continue to communicate directly with the Insured regarding coverage decisions. This Assignment is effective upon signature and may be revoked only by a written notice delivered to both the Provider and the Insurer; revocation will not affect payments previously made in reliance on this Assignment.

Certification and Authorization

I certify under penalty of perjury that I am the named Insured or an authorized representative of the Insured with full authority to execute this Assignment of Benefits. I authorize the Insurer to pay assigned benefits directly to the Provider and to release claim information and records as necessary to process payment. I understand that signing this document does not guarantee payment and that all payments are subject to the terms of the policy.

By signing below I acknowledge that I have read, understand, and accept the terms of this Assignment of Benefits and Authorization.

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