Miscellaneous AOB Notice

MISCELLANEOUS AOB NOTICE

Parties and Contact Information

This Notice of Assignment of Benefits (the "Notice") is given pursuant to the mutual agreements of the parties identified above. The parties hereby state and acknowledge the assignment described herein and the rights and obligations that arise as a result of that assignment.

WHEREAS

1. WHEREAS, Assignor is entitled to certain benefits, proceeds, claims, or recoveries arising under or related to the policy, contract, claim, or account identified below;

2. WHEREAS, Assignor desires to assign and transfer to Assignee, and Assignee desires to accept, all or specified rights to receive such benefits, proceeds, claims, or recoveries as set forth in this Notice;

3. WHEREAS, the parties intend that this Notice constitute a legally binding assignment of rights and a direction to any payor or obligor to recognize Assignee as the recipient of the assigned benefits to the extent set forth below.

Notice of Assignment of Benefits

To: ; Policy/Contract/Account No.: ; Claim No.:

Effective Date of Assignment: . Assignor hereby assigns, transfers, and conveys to Assignee all rights, benefits, claims, proceeds, and causes of action relating to the matters described herein, including the right to receive payment and to pursue recovery directly from the payor or other responsible parties to the full extent permitted by law and contract.

Scope of Work

The Assignee agrees to perform or procure the services described below in connection with the claim, including but not limited to advocacy, billing, documentation, repair, or other services necessary to secure payment of the assigned benefits. Assignor authorizes Assignee to act on Assignor's behalf to the extent required to pursue the assigned benefits.

Payment Terms

Amount Assigned / Fees: $ payable to Assignee as compensation for services and for the amounts described above. Payment shall be applied in the following manner:

Term and Termination

Term Commencement Date: . Term Expiration Date (if any): .

Either party may terminate this Notice for material breach that is not cured within the notice period specified above, or immediately upon fraud or material misrepresentation by the other party. Termination does not affect rights to payments already earned or received.

Confidentiality

The parties acknowledge that certain information exchanged in connection with the assigned benefits may be confidential or subject to privacy laws. Each party shall maintain in confidence all nonpublic business, medical, financial, and personal information received from the other and shall use such information solely for the purpose of administering and enforcing the assigned rights. Disclosure is permitted where required by law, court order, or with the prior written consent of the disclosing party.

By checking this box, the signing party acknowledges receipt of and agreement to the confidentiality provisions set forth above.

Representations and Warranties; Certifications

Assignor represents and warrants that it has the full right, title, and authority to assign the rights specified herein, that the assigned rights are free of liens and encumbrances except as disclosed in writing, and that Assignor will not further assign the same rights to any other person or entity without written notice to Assignee. Assignor certifies that the information provided in connection with this Notice is true, complete, and accurate to the best of Assignor's knowledge.

Governing Law

This Notice shall be governed by and construed in accordance with the laws of the State of without regard to conflict of law principles. Venue for any dispute arising under this Notice shall lie exclusively in the state or federal courts located in that State.

Entire Agreement

This Notice, together with any exhibits or written amendments signed by the parties, constitutes the entire agreement between the parties with respect to the assignment described herein and supersedes all prior negotiations, discussions, and agreements, whether written or oral.

Notices

All notices required or permitted under this Notice shall be in writing and delivered to the addresses set forth above or such other address as a party may designate in writing. Notices shall be deemed given upon personal delivery, three days after deposit in the U.S. mail, or one day after deposit with a nationally recognized overnight courier.

The parties have executed this Notice as of the dates set forth below. Each party represents that the person signing on its behalf is authorized to bind the party.

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