Authorization Form
This Authorization is HIPAA compliant
Date: ______________Advisor Name:____________________________Advisor Phone: ("!
) ____________
Insured Name: ______________________________________________ Date of Birth:_______________________
SSN: __________________________ Driver’s License #: __________________________State: _______________
The purpose of this Authorization is to permit MRW Financial to obtain and release nonpublic personal information about me, the Proposed
Insured named above, for the purposes of determining my eligibility for, and obtaining insurance products and services from, one or more of
the insurers or other institutions listed below.
I specifically authorize any physician or other medical practitioner, hospital, clinic, or other health-related facility, medical testing laboratory,
insurer, state motor vehicle department, my past or current employer(s), the Social Security Administration, and any other organization,
institution or person that has information or documentation about me to release such information and documentation to MRW Financial and
its authorized representatives. The information and documentation to be released to MRW Financial shall specifically include any and all
records and information regarding diagnosis, testing, treatment and prognosis of my physical or mental condition, including but not be limited
to, documents relating to my mental and physical health, mental health records, psychotherapy notes, drug/ alcohol abuse treatment records,
pharmacy prescriptions, HIV testing and treatment, STD testing and treatment, any other communicable disease records, genetic testing,
general reputation, mode of living, finances, occupation, driving records and other personal traits (“Information”).
In addition, I specifically authorize MRW Financial to release any and all Information it receives about me to the companies listed below. I
also specifically authorize MRW Financial and the companies listed below to release any and all Information about me to their respective
reinsurers, underwriters or other persons or organizations performing business, professional or insurance functions for them. I also authorize
the Medical Information Bureau, Inc. (MIB*) to release any and all Information about me directly to any company listed below, upon such
company’s request, provided the company is a member of MIB.
This Authorization shall be effective for two (2) years after the date signed below. I understand that I have the right to revoke this
Authorization at any time by sending a written notice of revocation to MRW Financial, 310 S. Dale Mabry Hwy., Ste. 210 , Tampa, FL 33609. I
understand that any action taken in reliance on this Authorization prior to MRW Financialʼs receipt of the written notice of the revocation shall
be valid. I also understand that any Information that is used or disclosed pursuant to this Authorization may be subject to re-disclosure by the
recipient and may no longer be protected under federal or state privacy rules.
I understand that execution of this Authorization is voluntary and that I can refuse to sign this Authorization. I understand that my refusal to
sign this Authorization will not affect my ability to obtain treatment or payment or my eligibility for health care benefits. However, I understand
that my refusal to sign this Authorization may prevent me from obtaining insurance products or services from one or more of the companies
below.
I acknowledge that I have read and understand the above and agree that this Authorization was completed prior to my signature. I further
agree that a copy of this Authorization, whether a photocopy, carbon copy, or otherwise, shall have equal standing as if it were an original
and can be relied upon by MRW Financial and/or any third party designated herein.
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Proposed Insured’s Signature / Guardian or Custodian / Authorized Representative!
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Date
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Broker / Advisor / Agency / Firm Signature !
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Date
AIG / American General
Gleaner
MetLife DI
Reliance Standard
AIG Annuity Access
Guarantee Trust Life
MetLife LTC
Savings Bank Life Insurance Co
Allianz
Illinois Mutual
Midland National
of MA
Allianz Life of NY
ING Northern Life
Minnesota Life
Security Mutual of NY
Allstate Life of NY
ING Reliastar
Mutual of Omaha
Standard Insurance Company
American National
ING Reliastar of NY
National Guardian
State Life/One America
American Investors Life
ING Security Life of Denver
National Integrity Life
Sun Life Financial
Assurity
ING Annuity and Life
National Life
Sun Life of Canada
AVIVA AXA Equitable
Integrity Life
Nationwide – Provident Mutual
Sun Life of NY
Banner Life
John Hancock Life
New York Life
Transamerica
Companion Life of NY
John Hancock LTC
North American
UNIFI Companies
Dearborn National
John Hancock of NY
OM Financial Life Insurance Co.
United of Omaha
Equitable Life and Casualty
John Hancock USA (MAN)
OM Financial Life Insurance Co.of
US Life on New York
Equitrust
Lafayette Life
NY
West Coast Life
Fidelity Life
Life of the Southwest
Pacific Life
Western Reserve Life
Fidelity Security
Lincoln Benefit
Penn Mutual
William Penn of NY
Genworth Life
Life Lincoln Life of NY
Petersen International
Zurich
Genworth Life & Annuity
Lincoln National
Phoenix Life Insurance Co.
Genworth Life and Annuity Ins.Co.
Lloyd’s of London
Presidential Life Principal
Genworth Life Ins. Co of NewYork
MassMutual
Principal National Protective Life
Genworth Life NY
MedAmerica
Protective Life of NY
Genworth LTC
MetLife Investors
Prudential Life
Other Company: __________________________________________________________________Insured Initials: ____________
MRW Financial will employ its best efforts to disclose information only to those insurance companies deemed necessary to provide
the best result for the proposed insured.
*MIB is a not for profit organization of life insurance companies and operates an information exchange for its members. Upon request of a member
company, in connection with determining your eligibility for insurance, MIB may supply that member company with information in its file. MIB, Inc. PO
Box 105 Essex Station, Boston, MA 02112 or call (617) 426-3660
MRW Financial Inc.
310 S. Dale Mabry Hwy., Ste. 210
Tampa, FL 33609
P (813) 875-6331 | TF (800) 967-7661 | F (813) 875-7331!
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For Advisor Use Only. Not for Public Dissemination. !
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Rev. 06/11