Claims Experience Authorization Form

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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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