Insurance Claim Authorization Release Form
Policyholder Information
Full Name
Policy Number
Address
Phone Number
Email Address
Claim Details
Claim Number
Date of Incident
Description of Incident
Authorized Party Information
Name of Person/Organization Authorized
Relationship to Policyholder
Purpose of Authorization
I hereby authorize the release of insurance claim information as indicated above. I understand that this authorization is voluntary and may be revoked at any time with written notice.
Signature
Date