Form Cl07353-3 - Insured'S Statement Of Loss Page 3

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CLAIM CONTACT
Authorization for Disclosure of Information Form Must be Completed.
By indicating an individual below and signing this form, the policyowner authorizes us to release information
regarding this claim to the individual named below.
Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
City: _____________________________________________ State: _______ ZIP: _______________________________
Home Phone: ______________________________________ Work Phone: _____________________________________
Relation to our Insured: ______________________________________________________________________________
SIGNATURES
Fraud Warning for New York Residents:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
______________________________________________________________
________________________________
Signature of Insured or Insured’s Legal Representative
Date
______________________________________________________________
________________________________
Print Name
Title
______________________________________________________________
________________________________
Signature of Policy Owner (if other than Insured)
Date
______________________________________________________________
________________________________
Print Name
Title
Page 3 of 4
CL07353-3
11/13

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