Sample insurance company authorization

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 239-239

A-221 Appendix: Sample Documents Form 9

FORM 9 SAMPLE INSURANCE COMPANY AUTHORIZATION

AUTHORIZATION FOR RELEASE OF INFORMATION

TO WHOM IT MAY CONCERN:

This will serve as authorization for you or your agents to discuss with and/or fur-

nish to LAW FIRM, ADDRESS, any information he desires in connection with the

employment, insurability, or representation of the undersigned.

I hereby grant to LAW FIRM authorization to represent me with respect to any and





otherwise represent me in the submission and prosecution of any claim or demand

 

trustee, claims processor, government agency or court.

-

uments, records or other information which he requests of any person, including

personnel records, payroll records, annual reports, plan documents, summary plan



health care records, medical records, and insurance records. I hereby agree to hold

harmless any person providing any documents, records, or other information to my

said attorney. You are authorized to furnish said attorney any documents, records

or other information for which he may ask, on my behalf.

A copy of this authorization is as valid as the original.

Signed: _____________________________

Client

Date: / /