Who can sign a release?

An authorized policyholder, named insured, or an officer with explicit authority may sign. For corporate policies, include title and authority; carriers may require proof of the signer's authority if not listed on the policy.

Can the form be e-signed?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.

Is notarization required?

Not typically required for loss run releases, but some states or carriers may request notarization or witness signatures. Verify state notary rules and carrier policies before assuming it is unnecessary.

What if insurer refuses to provide records?

Insurer may request corrected authorization, identity proof, or additional documentation. Review the rejection reason and provide the precise information requested to avoid delays.

How long do carriers keep records?

Retention varies by carrier and state; insurers commonly retain claim files for many years. Request archival search explicitly if the needed claims predate the carrier's online records.

How to revoke a release?

Revocation should be in writing and specify an effective date; revocation does not retroactively invalidate records already disclosed in reliance on a valid authorization.

Electronic Signature
Templates
Insurance
Insurance Loss Run Release Form

Insurance Loss Run Release Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE LOSS RUN RELEASE FORM

Insured / Applicant Information

Insured Name Doing Business As (DBA) / Trading As (if applicable) Entity Type

Individual Corporation LLC Partnership Other:

Mailing Address

Phone:

Email:

Date of Birth (if individual):

Policy Information

Insurance Carrier / Company

Policy Number:

Policy Type:

Coverage Limit:

Deductible:

Premium:

Policy Period Start: End:

Requested Loss Run Details

Requested Loss Run Period From: To:

Include in loss run (select all that apply):

Open claims Closed claims Reserves and payments Loss descriptions / cause of loss

Delivery method requested:

Email (provide address below) Certified Mail Fax Secure portal Other:

If Email selected, Delivery Email

Authorized Recipient / Third Party

Recipient Name Recipient Organization (if applicable)

Recipient Relationship to Insured:

Recipient Phone:

Recipient Address Recipient Email

Specific Claims / Identifiers (Optional)

List specific claim numbers, dates of loss, or other identifiers to be included

Exclusions, Limitations and Notice

The Insurer is authorized to disclose loss run reports and claim history information limited to claim numbers, dates of loss, status (open/closed), loss descriptions, reserves, payments, and associated claim financials for the policy(ies) and period(s) specified above. This authorization explicitly does not authorize disclosure of medical records, psychotherapy notes, privileged attorney work product, social security numbers beyond what is necessary for claim identification, driver license numbers, or other information protected by law unless separate specific written authorization is provided.

The Insurer may redact non-claim-related personally-identifiable data and may withhold information to the extent disclosure is prohibited by law or would violate third-party privacy rights. Delivery timelines are subject to the Insurer's normal records retrieval procedures.

Authorization, Release and Indemnity

I, the undersigned Insured or authorized representative, hereby authorize and direct the above-named insurer(s), their agents, adjusters, attorneys and administrators to release and disclose loss run reports, claim history, reserve and payment information, and related claim file documents for the policy(ies) and period(s) identified in this form to the Authorized Recipient named herein. This authorization includes disclosure in written, electronic and verbal form as required for the Recipient to evaluate or place coverage.

I certify that I am authorized to execute this release on behalf of the Insured and that the information contained herein is true and correct to the best of my knowledge. I understand that this release is not a change in coverage and does not waive any defenses of the Insurer. I further agree to indemnify and hold harmless the Insurer and its representatives for any claims, liabilities, losses or damages arising solely from disclosing records pursuant to this authorization to the Authorized Recipient, except to the extent caused by the Insurer's gross negligence or willful misconduct.

This authorization will remain in effect for 180 days from the date of signature below unless earlier revoked in writing and delivered to the Insurer. Revocation will not affect disclosures made prior to receipt of the revocation.

By placing my signature below I acknowledge that I have read and understand this Loss Run Release, that I am authorized to request and receive the requested loss runs, and that I accept the terms, conditions, limitations and indemnities set forth herein.

Insured / Authorized Representative (Print Name):

Signature:

Date:

Title / Capacity:

Organization (if signing for an entity):

What the Insurance Loss Run Release Form Is

An Insurance Loss Run Release Form authorizes an insurer or third party to disclose a policyholder's claims history (loss runs) to a designated recipient such as an agent, broker, underwriter, or prospective insurer. Loss runs summarize claim dates, amounts paid, reserves, and claim status over a specified period and are commonly used for policy renewals, underwriting, and risk assessment. The release documents consent, identifies the records requested, and sets the time window for the disclosure.

Why a Clear Release Form Matters

A precise Insurance Loss Run Release Form expedites underwriting, reduces disputes over omitted claims, and documents consent for record disclosure while protecting privacy and compliance obligations.

Who Typically Completes and Receives This Form

Properly completed releases speed the underwriting cycle and provide a clear audit trail of consent.

Insurance agents and brokers requesting loss history for renewal or quote purposes.
Commercial or personal policyholders authorizing disclosure to a new insurer or advisor.
Underwriters and risk managers who require claim detail to assess coverage terms and pricing.

Step-by-Step: Completing the Release Form

Follow these sequential steps to complete the Insurance Loss Run Release Form accurately and consistently.

01

Gather documents: Collect policy number, insurer name, and claimant details before starting.
02

Define scope: Specify the exact claim period and types of records to be released.
03

Identify recipient: Enter full name and contact information for the party authorized to receive records.
04

Sign and date: Authorized signer signs, prints name, dates, and indicates relationship to the insured.

How to Configure an Online Release Workflow

When digitizing the release, configure authentication, fields, and routing to preserve legal validity and auditability.

Field	Configuration
Authentication Method	Email link with SMS code for stronger signer attribution
Required Fields	Policy number, insured name, claim period, recipient info
Routing Order	Insured signs first, then broker or agent receives copy
Retention Settings	Enable automatic archival and export to PDF/A

Typical Digital Exchange: From Request to Delivery

A standard e-submission flow reduces manual handoffs and records signer activity for compliance purposes.

Upload Document: Sender uploads the release and places required fields.
Add Signers: Enter signer emails and specify signing order if needed.
Authenticate: Signer verifies identity (email link, SMS code, or stronger methods).
Deliver Records: Insurer transmits loss run PDF to the authorized recipient.

Delivery and Format Considerations for eSubmission

Select settings that preserve signed copies, produce certificates of completion, and integrate with your records system.

File Formats: PDF, DOCX accepted; use flattened PDF for record copies
Integrations: Connectors: Salesforce, NetSuite, Google Workspace
Authentication: Support for SMS, email tokens, or advanced signer verification

Elements of a Professional Loss Run Release

A complete form balances clarity for the insurer with explicit authorization from the policyholder; include these essential elements.

Authorized Parties

Name the specific recipient(s) permitted to receive loss runs and include contact details for delivery.

Record Scope

Define the time period and types of records (paid, reserved, closed, open claims).

Purpose Statement

State the business reason for disclosure (renewal, quote, audit) to limit misuse.

Consent Language

Clear phrasing granting insurer permission to share records with listed parties.

Signature and Date

Signature by authorized individual with printed name and relationship to insured.

Revocation Terms

How and when authorization may be withdrawn and the effective date of revocation.

Security and Compliance Considerations

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Audit Trail: Timestamp, IP, and action log retained

HIPAA Support: BAA available when handling PHI

21 CFR Part 11: Supports FDA-regulated electronic records

SOC 2 Type II: Independent security attestation available

Access Controls: Role-based and MFA options

Common Pitfalls to Avoid

Requesting an overly broad release without defined dates can delay fulfillment while the insurer clarifies scope and may trigger privacy checks.
Entering an incorrect policy number or abbreviated carrier name often causes insurers to return the request as non-matching.
Omitting the signer relationship (owner, authorized agent, corporate officer) can invalidate the release or require additional documentation.
Failing to specify delivery method (secure portal vs email) can delay receipt and create auditability gaps.

Consequences of Incomplete or Incorrect Releases

Delayed Underwriting: Incomplete forms can delay quotes and renewals by days or weeks

Privacy Fines: Unauthorized disclosures risk HIPAA or state privacy violations

Denial of Request: Insurer may refuse to release records pending corrected authorization

Inaccurate Pricing: Missing claims distort loss history and premium calculations

Legal Disputes: Ambiguous releases may lead to contractual disputes

Operational Costs: Rework and manual follow-up increase administrative expense

Typical Timelines and Processing Expectations

Turnaround times depend on insurer processes; include realistic expectations and escalation paths when time is critical.

Standard Response Time:

Many insurers provide loss runs within 7–30 calendar days.

Expedited Requests:

Some carriers offer expedited handling for a fee or prioritized processing.

Follow-up Window:

Allow 7–10 days after submission before escalating to a supervisor.

Record Retention:

Insurers may access archived records requiring longer retrieval times.

Notification of Rejection:

Insurer should notify requester promptly if the release is invalid or incomplete.

eSignature Vendor Comparison for Completing the Release Form

Key vendor features and starting prices for common eSignature tools. signNow is listed first for column alignment and feature comparison.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Practical Examples of Release Form Use

Two concise scenarios illustrate how the release is used in typical workflows.

Agent Request

An agent obtains signed release to request loss runs

The insurer validates policy number and returns a CSV/PDF of claims
The agent attaches loss runs to renewal submission, reducing follow-up and accelerating underwriting review.

Broker Renewal

A broker collects releases from multiple insureds for a placement

Each carrier delivers loss runs via secure portal
The broker compiles loss histories to negotiate terms and document the basis for pricing decisions.

Best Practices for Accurate and Efficient Completion

Follow these practical tips to minimize processing time and ensure the release is accepted on first submission.

Use Exact Identifiers

Always provide full policy number and insurer legal name to avoid matching errors and reduce manual research.

Limit Scope

Request only necessary claim periods and record types to speed retrieval and preserve privacy.

Preserve Audit Trails

Use eSignature platforms with detailed certificates of completion to document consent and attribution.

Confirm Delivery Method

Specify secure portal delivery or encrypted email and include recipient contact details for faster processing.

Frequently Asked Questions About Loss Run Releases

Answers to common questions about scope, authority, electronic signing, and what to do if a request is rejected.

Need help? Contact support

Who can sign a release?
An authorized policyholder, named insured, or an officer with explicit authority may sign. For corporate policies, include title and authority; carriers may require proof of the signer's authority if not listed on the policy.
Can the form be e-signed?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.
Is notarization required?
Not typically required for loss run releases, but some states or carriers may request notarization or witness signatures. Verify state notary rules and carrier policies before assuming it is unnecessary.
What if insurer refuses to provide records?
Insurer may request corrected authorization, identity proof, or additional documentation. Review the rejection reason and provide the precise information requested to avoid delays.
How long do carriers keep records?
Retention varies by carrier and state; insurers commonly retain claim files for many years. Request archival search explicitly if the needed claims predate the carrier's online records.
How to revoke a release?
Revocation should be in writing and specify an effective date; revocation does not retroactively invalidate records already disclosed in reliance on a valid authorization.

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