Claims Experience Authorization Form printable pdf download

Claims Experience Authorization Form

CLAIMS EXPERIENCE AUTHORIZATION FORM

Date: ___________________

Name:

_________________________________________________________________

Address: _________________________________________________________________

Telephone Number: _________________________

Policy Number(s):

_________________________

I am requesting and authorizing that my Insurance Company, ___________________________ ,

provide an experience letter for myself and the following drivers listed on the policy. I

understand that an experience letter contains personal information about me that has been

collected while I have been insured with the above insurance company.

Name _________________________

Signature ___________________________

Name _________________________

Signature ___________________________

Name _________________________

Signature ___________________________

Name _________________________

Signature ___________________________

Please provide a copy to the following party and also provide a copy to

____________________________________ (named insured) at the above noted address.

Name:

___________________________________________________________

Address:

___________________________________________________________

Fax Number: ___________________________________________________________

Insured’s signature:

______________________________________________

Insured’s signature:

______________________________________________

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Claims Experience Authorization Form