Who can sign the release?

An authorized officer, named insured, or a person with written authorization may sign. For businesses, include title or attach a corporate resolution if requested by the insurer.

Are electronic signatures valid?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA, provided intent, consent, attribution, and retention requirements are met.

When is notarization required?

Notarization depends on insurer policy or state law. If an insurer or transaction requires notarization, follow state notary rules or use RON where permitted.

How long will insurers take to respond?

Timing varies; expect an acknowledgement within 3–10 business days and delivery within 10–30 business days unless an expedited option is arranged.

Can I revoke a release once sent?

Revocation may be limited after the insurer has acted. Include expiration language in the release and notify recipients immediately to attempt any revocation.

What if loss run data is incorrect?

Submit a written dispute to the insurer with supporting documentation; allow 30–60 days for correction and consider attaching the dispute to renewal negotiations.

Electronic Signature
Templates
Insurance
Insurance Loss Runs Release

Insurance Loss Runs Release

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

INSURANCE LOSS RUNS RELEASE

Parties and Applicant Information

Applicant / Insured Name

Entity Type (check one) Individual Corporation Limited Liability Company Partnership

Applicant Address

Telephone:

Email:

Date of Birth: / /

Policy and Coverage Details

Insurer / Carrier Name

Policy Number:

Policy Type:

Coverage Limit:

Deductible:

Annual Premium:

Policy Period: From / / to / /

Coverage Types (select all applicable)

General Liability Property Auto Workers' Compensation Professional Liability Cyber Liability

Loss Runs Requested

Requested Loss Run Period: From / / to / /

Information Requested (check all that shall be disclosed)

Claim numbers Dates of loss Current reserves Loss payments Open/closed status Adjuster contact information Adjuster/claim notes

Specific Claims or Claim Numbers Requested (if any)

Authorized Recipient and Purpose

Authorized Recipient Name Recipient Address / Contact Purpose of Disclosure

Authorization Duration (in days): or until revoked in writing by the Applicant.

Exclusions and Limitations

This Release does not authorize disclosure of privileged attorney-client communications, privileged claim legal files, or medical records beyond those portions of the claim file necessary to reflect loss payments, reserves, dates of loss, and cause. The Carrier or record holder may redact information not directly relevant to loss history where disclosure would violate other legal obligations or privacy laws.

Acknowledgement of Exclusions I acknowledge and accept the exclusions and limitations listed above

Release, Certification and Indemnity

The Applicant hereby authorizes and instructs any current or prior insurer, insurance agent, managing general agent, third party administrator, or claims administrator having custody of Applicant's claim files and loss runs to disclose to the Authorized Recipient the requested loss history information for the periods and coverages specified above. The Applicant expressly releases such entities from liability for disclosure of claim and loss information pursuant to this authorization to the extent permitted by law.

The Applicant certifies that the information provided in this Release is true and correct to the best of Applicant's knowledge and that this Release is executed voluntarily for the stated purpose. The Applicant agrees to indemnify and hold harmless any Carrier or record holder for any claim, demand, damage, loss, cost or expense (including reasonable attorneys' fees) arising from reliance on this Release, except to the extent that such claim is caused by the willful misconduct or gross negligence of the Carrier providing the information.

This Release is governed by the laws of the state indicated by the Applicant's address and shall be binding upon the Applicant and the Applicant's heirs, successors, and assigns. Any revocation of this authorization must be delivered in writing to the Authorized Recipient and to the Carrier from which records are sought; revocation shall not affect disclosures made in good faith prior to receipt of revocation.

Certification (must be checked) I certify under penalty of perjury that I am authorized to request and release the requested loss run information on behalf of the Applicant named above.

Beneficiary / Claim Proceeds Contact (Optional)

Beneficiary or Payee Name

Relationship:

Percentage:

Supplemental Information / Notes

Additional Instructions or Notes to Carrier

Acknowledgement and Signature

By signing below, the Applicant affirms that they have read and understand this Insurance Loss Runs Release and voluntarily authorize the disclosure described herein.

Applicant Name:

Signature:

Date:

What the Insurance Loss Runs Release Is and when it matters

An Insurance Loss Runs Release is a signed authorization that allows an insured party or its broker to obtain claims history reports (loss runs) from an insurer or third-party administrator. These reports summarize prior claims activity by policy period, claim date, reserve amounts, payment history and status. Underwriting, renewal negotiations, mergers and acquisitions, and premium audits commonly require loss runs to assess risk exposure. The release clarifies the scope and time period of the request and identifies the requester so insurers can respond without violating privacy or contract provisions.

Why a clear release benefits underwriting and compliance

A precise Insurance Loss Runs Release speeds insurer response, reduces disputes about scope, and preserves accurate records for underwriting decisions. It helps ensure only authorized parties receive sensitive claims data and documents the insured’s consent to share loss history with brokers, carriers, or prospective buyers.

Step-by-step: Completing an Insurance Loss Runs Release

Follow these sequential steps to prepare a compliant, usable release that insurers accept without delay.

01

Identify parties: Enter insured and insurer full legal names and contact details.
02

Define scope: Specify claim types, policy numbers, and date range requested.
03

Authorize disclosure: Include explicit language permitting release to named recipients.
04

Sign and date: All required signatories must sign and include execution date.

Essential elements to include in a professional release

A thorough Insurance Loss Runs Release combines identification, scope, authority, and execution details so insurers can process requests reliably.

Party Identification

Full legal names and contact information for the insured, insurer, and requester so records match policy files and delivery is directed correctly.

Scope of Records

Clear description of the data requested: loss types, indemnity payments, reserves, subrogation status, medical payments, and claim notes where permitted.

Policy References

List of policy numbers, policy periods, and lines of coverage tied to the request so administrators locate the correct files efficiently.

Authorization Language

Specific consent clause naming authorized recipients and stating that the insurer may release loss runs to those recipients for underwriting or audit purposes.

Execution Details

Signature block with printed name, title, date, and witness or notary details if required by the insurer or jurisdiction.

Retention and Use

Statement limiting use of the loss runs to underwriting, renewal, or transaction purposes and noting any confidentiality obligations.

Required data points insurers typically expect

Insured Name: Legal name

Policy Number: Exact number

Date Range: MM/DD/YYYY

Authorized Recipient: Name & contact

Signature: Signed & dated

Purpose: Underwriting use

How to customize an online release workflow

Configure the digital request so signers, recipients, and auditors receive the right fields and notifications.

Form Template	Create a reusable release template with locked scope fields to standardize requests.
Conditional Fields	Show policy number field only when 'Yes' is selected for 'Attach policy details.'
Signer Roles	Assign roles (Insured, Broker, Authorized Rep) with required fields per role.
Authentication	Select email link, SMS code, or ID verification per insurer preference.
Delivery Options	Choose secure PDF delivery, encrypted email, or direct insurer portal upload.

Technical considerations for electronic submission

Verify the recipient insurer’s accepted formats, authentication expectations, and any notarization or witness requirements before sending the release.

File Formats: PDF, DOCX
Authentication: Email or SMS code
Recordkeeping: Audit trail

Typical routing: who sends, who signs, and who receives loss runs

A common routing sequence ensures authorization and delivery: insured signs, broker requests, insurer releases to listed recipients and retains an audit trail.

Insured signs: Insured executes release and returns to broker or requester.
Broker requests: Broker submits the signed release to insurer or TPA.
Insurer processes: Insurer matches policy and compiles loss runs.
Recipients receive: Designated recipients get certified copy and audit record.

Typical processing timelines and expectations

Timelines vary by carrier and volume; set expectations clearly in the request to avoid delays.

Initial Response Time:

Carrier acknowledgement within 3–10 business days.

Standard Delivery:

Loss runs delivered in 10–30 business days depending on backlog.

Expedited Requests:

Some insurers offer 24–72 hour expedited delivery for a fee.

Retention of Request:

Insurer may retain request records per its recordkeeping policy.

Dispute Resolution:

Allow 30–60 days for investigation of contested entries.

Common preparation mistakes that slow or block release

Omitting exact policy numbers or using informal trade names that do not match insurer records, which leads to mismatches and rejection.
Using vague date ranges such as 'last five years' without clear start and end dates, causing insurers to request clarification.
Failing to name all authorized recipients or providing incomplete contact information that prevents secure delivery of loss runs.
Submitting unsigned or improperly witnessed releases when the insurer’s policy or state law requires notarization or additional authentication.

Key legal and operational risks to watch for

Privacy breach: HIPAA violation risk

Denial of request: Insurer may refuse

Underwriting delay: Renewal impacted

Incorrect data: Premium miscalculation

Unauthorized disclosure: Contract liability

Notarization lapse: Legal invalidity

eSignature solution pricing snapshot for executing releases

Compare common vendor pricing and features relevant to signing and distributing Insurance Loss Runs Releases; signNow is listed first per vendor comparison guidance.

	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	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Typical requesters and signers of loss runs releases

Multiple parties commonly prepare or sign a release depending on the context — understand who needs to be involved for your use case.

Brokers and agents who need loss runs to quote or renew coverage and to advise insureds during placement or negotiation.
Risk managers and corporate legal teams requesting historical claims data for M&A, diligence, or internal audits.
Authorized insured representatives or third-party administrators who have written authority to request or accept loss history on behalf of the insured.

Frequently asked questions about Insurance Loss Runs Releases

Answers to common procedural and legal questions when preparing, signing, and submitting loss runs releases.

Need help? Contact support

Who can sign the release?
An authorized officer, named insured, or a person with written authorization may sign. For businesses, include title or attach a corporate resolution if requested by the insurer.
Are electronic signatures valid?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA, provided intent, consent, attribution, and retention requirements are met.
When is notarization required?
Notarization depends on insurer policy or state law. If an insurer or transaction requires notarization, follow state notary rules or use RON where permitted.
How long will insurers take to respond?
Timing varies; expect an acknowledgement within 3–10 business days and delivery within 10–30 business days unless an expedited option is arranged.
Can I revoke a release once sent?
Revocation may be limited after the insurer has acted. Include expiration language in the release and notify recipients immediately to attempt any revocation.
What if loss run data is incorrect?
Submit a written dispute to the insurer with supporting documentation; allow 30–60 days for correction and consider attaching the dispute to renewal negotiations.

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