AUTHORIZATION FOR RELEASE OF INSURANCE INFORMATION

Coverage Investigation and Claims Documentation

SECTION 1: POLICYHOLDER/INSURED INFORMATION

Name: [________________________________]

Date of Birth: [________________________________]

Social Security Number: [________________________________]

Driver's License Number: [________________________________] State: [____]

Current Address:
Street: [________________________________]
City, State, Zip: [________________________________]

Phone Number: [________________________________]

Email Address: [________________________________]

SECTION 2: AUTHORIZATION

I, [NAME], hereby authorize the insurance company(ies) and agent(s) identified below to release complete policy information, claims history, and other records to:

Authorized Recipient:
Attorney/Firm Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

This authorization relates to an incident that occurred on [DATE OF INCIDENT].

SECTION 3: AUTOMOBILE INSURANCE

Primary Auto Policy

Insurance Company: [________________________________]

Policy Number: [________________________________]

Named Insured(s): [________________________________]

Policy Period: [________] to [________]

Agent Name: [________________________________]

Agent Address: [________________________________]

Agent Phone: [________________________________]

Claim Number (if assigned): [________________________________]

Adjuster Name: [________________________________]

Adjuster Phone: [________________________________]

Information Requested:

☐ Complete declarations page(s) showing all coverages and limits
☐ Complete policy including all endorsements and amendments
☐ Certificate of insurance
☐ Claims history for past 5 years
☐ Proof of premium payment
☐ Coverage denial letters (if any)
☐ Reservation of rights letters (if any)
☐ Claim file and investigation documents
☐ Photographs of vehicles
☐ Recorded statements
☐ All correspondence regarding this claim
☐ Payment records and checks issued
☐ Subrogation documents

Coverage Verification Needed:

SECTION 4: ADDITIONAL HOUSEHOLD AUTO POLICIES

Additional Policy 1:
Policyholder: [________________________________]
Relationship: [________________________________]
Insurance Company: [________________________________]
Policy Number: [________________________________]
UM/UIM Limits: $[____]/$[____]

Additional Policy 2:
Policyholder: [________________________________]
Relationship: [________________________________]
Insurance Company: [________________________________]
Policy Number: [________________________________]
UM/UIM Limits: $[____]/$[____]

SECTION 5: AT-FAULT PARTY INSURANCE

Adverse Party Name: [________________________________]

Insurance Company: [________________________________]

Policy Number: [________________________________]

Claim Number: [________________________________]

Adjuster Name: [________________________________]

Adjuster Phone: [________________________________]

Information Requested:

☐ Confirmation of coverage for date of loss
☐ Bodily injury liability limits
☐ Property damage liability limits
☐ Umbrella/excess coverage
☐ Number of claimants
☐ Policy exhaustion status

SECTION 6: HEALTH INSURANCE

Insurance Company: [________________________________]

Policy Number: [________________________________]

Group Number: [________________________________]

Policyholder Name: [________________________________]

Member ID: [________________________________]

Claims Address: [________________________________]

Phone: [________________________________]

Plan Type:
☐ HMO ☐ PPO ☐ EPO ☐ HDHP ☐ Other: [________]

ERISA Plan: ☐ Yes ☐ No ☐ Unknown

Information Requested:

☐ Summary Plan Description (SPD)
☐ Certificate of Coverage
☐ Subrogation/reimbursement policy language
☐ Explanation of Benefits (EOBs) for injury-related treatment
☐ Payment records for injury-related claims
☐ Total amount paid for injury-related treatment
☐ Coordination of Benefits provisions
☐ Contact for subrogation/third-party liability department

SECTION 7: MEDICARE/MEDICAID

Medicare Information:

Medicare Beneficiary: ☐ Yes ☐ No

Medicare Number (HICN/MBI): [________________________________]

Part A Effective Date: [________________________________]

Part B Effective Date: [________________________________]

Medicare Advantage Plan: ☐ Yes ☐ No
Plan Name: [________________________________]

Medicaid Information:

Medicaid Beneficiary: ☐ Yes ☐ No

Medicaid Number: [________________________________]

State: [________________________________]

Information Requested:

☐ Conditional payment information
☐ Rights and responsibilities letter
☐ Lien amount and supporting documentation
☐ Contact information for Benefits Coordination & Recovery Center (BCRC)

SECTION 8: HOMEOWNER'S/RENTER'S INSURANCE

Insurance Company: [________________________________]

Policy Number: [________________________________]

Property Address: [________________________________]

Agent Name: [________________________________]

Agent Phone: [________________________________]

Information Requested:

☐ Declarations page
☐ Personal liability limits
☐ Medical payments to others
☐ Umbrella/excess coverage
☐ Animal liability coverage
☐ Exclusions and endorsements

SECTION 9: COMMERCIAL/BUSINESS INSURANCE

Business Name: [________________________________]

Insurance Company: [________________________________]

Policy Number: [________________________________]

Policy Type:
☐ Commercial Auto
☐ Commercial General Liability (CGL)
☐ Professional Liability
☐ Product Liability
☐ Umbrella/Excess
☐ Other: [________________________________]

Information Requested:

☐ Declarations page showing all coverages
☐ Complete policy with endorsements
☐ Certificate of insurance
☐ Named insureds and additional insureds
☐ Excess/umbrella coverage

SECTION 10: UMBRELLA/EXCESS LIABILITY

Insurance Company: [________________________________]

Policy Number: [________________________________]

Policy Limits: $[________________________________]

Underlying Coverage Requirements: [________________________________]

Information Requested:

☐ Complete policy
☐ Declarations page
☐ Self-insured retention
☐ Drop-down coverage provisions
☐ Excess coverage trigger requirements

SECTION 11: WORKERS' COMPENSATION

Workers' Comp Carrier: [________________________________]

Policy/Claim Number: [________________________________]

Employer Name: [________________________________]

Date of Injury: [________________________________]

Information Requested:

☐ Workers' compensation benefits paid
☐ Medical expenses paid
☐ Indemnity benefits paid
☐ Subrogation/reimbursement claim
☐ Employer liability coverage
☐ Excess workers' compensation coverage

SECTION 12: EXPIRATION AND REVOCATION

This authorization shall remain valid until:

☐ [SPECIFIC DATE]
☐ One (1) year from the date of signature
☐ Conclusion of the legal matter, including all appeals
☐ Written revocation by the undersigned

I understand I may revoke this authorization at any time by providing written notice to the insurance company(ies) identified above. Revocation will not affect disclosures made prior to receipt of the revocation notice.

SECTION 13: ACKNOWLEDGMENTS

I understand and acknowledge that:

☐ I am authorizing the release of confidential insurance policy and claims information.

☐ This information will be used to evaluate and pursue claims related to my injuries.

☐ Insurance coverage information may be shared with adverse parties during litigation.

☐ I have the right to receive a copy of this authorization.

☐ The insurance company may charge reasonable fees for copies as permitted by law.

SECTION 14: SIGNATURE

By signing below, I authorize the release of insurance information as described above.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

Witness (if required):

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

SECTION 15: COVERAGE INVESTIGATION LETTER

[LAW FIRM LETTERHEAD]

DATE: [________________________________]

VIA: ☐ Fax ☐ Email ☐ Mail ☐ Portal

TO:
[INSURANCE COMPANY NAME]
[ADDRESS]
[CITY, STATE ZIP]

RE: Coverage Investigation
Insured: [________________________________]
Policy Number: [________________________________]
Claim Number: [________________________________]
Date of Loss: [________________________________]

Dear Claims Representative:

This firm represents [CLIENT NAME] in connection with injuries sustained on [DATE OF INCIDENT].

Enclosed please find a signed authorization from our client permitting release of policy information.

Please provide the following within 15 business days:

For Claimant's Own Carrier:
1. Certified copy of declarations page effective on date of loss
2. Complete policy including all endorsements
3. Confirmation of all applicable coverages and limits:
- Medical Payments / PIP
- Uninsured Motorist (UM)
- Underinsured Motorist (UIM)
- Umbrella/Excess coverage

For Adverse Party's Carrier:
1. Written confirmation of coverage for date of loss
2. Bodily injury liability limits
3. Property damage liability limits
4. Existence of umbrella/excess coverage
5. Number of claimants asserting claims against these limits

For Health Insurance:
1. Subrogation/reimbursement policy language
2. Total amount paid for injury-related treatment
3. Contact information for subrogation department

Please direct all correspondence and inquiries to:

[ATTORNEY NAME]
[LAW FIRM NAME]
[ADDRESS]
[PHONE] | [FAX] | [EMAIL]

Thank you for your prompt attention to this matter.

Very truly yours,

[ATTORNEY SIGNATURE]
[ATTORNEY NAME]
Attorney for [CLIENT NAME]

Enclosure: Authorization for Release of Insurance Information

COVERAGE VERIFICATION CHECKLIST

For Law Firm Use:

Client's Own Coverage:

Adverse Party Coverage:

Health Insurance Liens:

Government Liens: