Medical Authorization (HIPAA Compliant) (Spanish)
Authorization form for disclosure of medical records, in compliance with HIPAA requirements.
PDF (76KB)
Forms Property & Casualty
Affidavit Of Salvage Retention (Spanish)
Acknowledgment by the current owner that his vehicle has been declared a total loss, and that he/she has elected to retain the salvage for a specific sum of monies. Towing and storage charges are also specified.
PDF (68KB)
Forms Property & Casualty
Automobile Accident Promissory Note (Spanish)
Customized automobile subrogation promissory note which allows the insurance company to notify DMV/BMV in case of default by the tortfeasor.
PDF (56KB)
Forms Property & Casualty
Affidavit Of Vehicle Theft (Spanish)
This legal form must be filled out by the insured and notarized. Includes information on vehicle ownership, description & condition, financing, as well as details regarding the theft and police report.
PDF (85KB)
Forms Property & Casualty
Denial - No Coverage (Spanish)
This form letter identifies the claimant, insurer, adjuster and date of loss; it is a claim denial for lack of coverage under the insured's policy.
DOC (45KB)
Letters
Automobile Accident Report - NY (Spanish)
Report form, customized for New York, that is given to vehicle owners and drivers to capture the details of an accident. Includes occupants, injuries, property damages, crash diagram, driver's account of accident, and witnesses.
PDF (55KB)
Forms Property & Casualty
Passengers Statement (Spanish)
A passenger's statement describes persons, vehicles, injuries, driver actions and circumstances of a crash.
PDF (85KB)
Forms Property & Casualty
Certificate Of Satisfaction (Spanish)
The insured signs this form which certfies his/her satisfaction with damage repairs performed, directs claim payment to that service provider, and closes the claim.
PDF (22KB)
Forms Property & Casualty
Receipt & Release Medical Payments Coverage (Spanish)
This form is signed by those who qualify as insureds under a policy when collecting medical payments coverage. Used as both a receipt and a release.
PDF (25KB)
Forms Property & Casualty
Non-Waiver Agreement / Reservation Of Rights (Spanish)
The non-waiver agreement is signed by the policyholder; its purpose is to protect the insurer. Insurer reserves all of its rights under the policy to investigate and defend a claim without admission of any liability for loss.
PDF (65KB)
Forms Property & Casualty
Power Of Attorney (Auto) (Spanish)
This is a limited power of attorney which grants the insurer permission to transfer title for a specific vehicle on the owner's behalf.
PDF (65KB)
Forms Property & Casualty
