Subrogation Authorization and Assignment

I hereby authorize and assign to (the "Company") all rights, title and interest to pursue and recover for any and all claims, demands, or causes of action arising from the incident described below, including but not limited to any insurance proceeds and subrogation rights.

Incident Details

Date of Loss:

Claim Number:

Description of Incident:

Policyholder Information

Name:

Address:

Phone:

Email:

I understand that by executing this document, I assign my right of recovery to the Company to the extent of their payment and authorize them to request, receive or inspect any and all documents relating to this claim.

Signature:

Date: