Auto Insurance Information Disclosure Consent Form

Name of Insured: Policy Number: Insurance Company: Policy Effective Date:

Consent to Disclose Insurance Information

I hereby authorize the insurance company named above to disclose my auto insurance information to the party/entities specified below. This information may include policy details, coverage limits, and claim history as necessary.

Recipient/Entity Name: Purpose of Disclosure:

I acknowledge that I have read and understand this consent form and authorize the disclosure as stated above.

Signature of Insured: Date: