Insurance Policyholder Rights Notice

Insurance Policyholder Rights Notice

Policy and Insured Identification

Insurer Name:

Policyholder / Insured

Date of Birth:

Policy Details

Policy Period: From to

Covered Perils and Coverage Options

The policy provides the coverages selected below. Check boxes indicate coverages in effect for the listed policy period.

Liability
Property / Physical Damage
Collision
Comprehensive
Personal Injury Protection
Uninsured / Underinsured Motorist
Other (describe below)

Exclusions and Limitations

The policy contains exclusions, limitations and conditions that may affect coverage. The following space is provided to summarize material exclusions applicable to this policy.

Beneficiary / Payee Designation

Provide beneficiary or payee information where applicable. Percentages must total 100% when multiple beneficiaries are named.

Policyholder Rights — Summary and Procedures

1. Right to Copies: You have the right to receive a complete copy of your policy, including all endorsements, riders, and the declarations page. Requests for copies will be honored within a reasonable period and at no additional charge when required by the policy.

2. Right to Explanation of Benefits and Denials: If a claim is denied, reduced, or otherwise contested, you have the right to a written explanation of the reasons and the evidence relied upon. You may submit additional information for reconsideration and request an internal appeal.

3. Right to File a Complaint or Grievance: You may file a written complaint or grievance regarding coverage decisions, service, or handling of claims. The insurer will provide an acknowledgment and an estimated timeframe for resolution. Use the contact information below to initiate a grievance.

4. Right to Notice of Cancellation or Nonrenewal: The insurer must provide written notice specifying the reason for cancellation or nonrenewal as set forth in the policy. You may request a written statement of the factual basis for the action.

5. Privacy and Personal Information: You have the right to be informed of the insurer's practices for collecting, using, and disclosing personal information. You may request correction of personal information used in underwriting or claim determinations.

6. Right to Appoint a Representative: You may designate an authorized representative to act on your behalf in communications with the insurer, including filing claims and appeals. Provide representative contact information to the insurer in writing.

Complaint / Appeal Contact Information

Acknowledgement of Receipt

By checking the boxes below and signing this notice, the policyholder acknowledges receipt of this Policyholder Rights Notice and understands the rights and procedures described herein. Checking a box does not waive any statutory rights afforded by applicable law.

I acknowledge I have received a copy of this Policyholder Rights Notice.
I acknowledge I have been informed of privacy and information practices relevant to underwriting and claims.
I acknowledge I have been informed about claim filing and appeal procedures.

Certification

I certify under penalty of perjury that the information provided on this notice is true and correct to the best of my knowledge. I acknowledge that I have read and understand the policyholder rights summarized herein and that I may exercise those rights in accordance with the policy and applicable law. I understand that willful misrepresentation or omission of material facts in connection with a claim or application may be subject to civil or criminal penalties where provided by law.

Additional Notes (Insurer Use)

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