Authorization for Release of Insurance Information


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:   (____ )_____ -__________

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