Free Insurance Power of Attorney Form

Please fill out this form to authorize someone to manage or act on your behalf in insurance-related matters.
Grantor Information
Name
Address
Phone Number
Authorized Representative Information
Name
Address
Phone Number
Relationship to Grantor
Authorization Details
I,
Powers Granted
Check all that apply:
Managing and modifying existing insurance policies
Filing insurance claims and appeals
Communicating with insurance companies and agents
Receiving claim payments or settlements
Purchasing new insurance policies
Effective Date
Termination Date
This power of attorney will remain in effect until:
By signing below, I confirm that I understand and agree to the terms of this authorization.
Name:
Date:
Name:
Date:
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