INSURANCE INFORMATION RELEASE AUTHORIZATION
To whom it may concern:__________________________________
Having employed the legal services of ________________________, I
hereby authorize the bearer of this document (or a photocopy of same) to
release to___________________ , any and all documents relating to any
insurance coverage I have ever had with the institutions which this document
(or aphotocopy of same) is submitted to by_____________________ , I also
authorize all such institution and their employees to discuss any confidential
matter relating to these coverages with ___________________________ ,.
Dated:______________________
Social Security Number:_________________________
Date of Birth:____________________
Attorney:_______________________
Mailing Address:
P.O. Box______
______________,_____ ________
Physical Address:
__________________
______________,_____ ________
Telephone Number: (____ )_____ -__________
Attorney Specific Forms
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