Your Company Name
Your Address
Your Phone Number
Your Web Address
ASSIGNMENT OF INSURANCE BENEFITS
“IT’S ABOUT JUSTICE”
Client/Insured
Policy Number
Claim Number
Insurer
Date of Loss
I. ASSIGNMENT OF INSURANCE BENEFITS
I, hereby, assign any and all insurance rights, benefits, proceeds and any causes of action under any
applicable insurance policies to (Insert Your Company Name) (hereinafter referred to as “Company”),
for services rendered or to be rendered by Company. In this regard, I waive my privacy rights. I
make this assignment in consideration of Company’s agreement to perform services and supply
materials and otherwise perform its obligations under this contract, including not requiring full
payment at the time of service. I also hereby direct my insurance carrier(s) to release any and all
information requested by Company, its representative, and/or its Attorney for the direct purpose of
obtaining actual benefits to be paid by my insurance carrier(s) for services rendered or to be
rendered. I believe the appropriate insurance carrier to be (Insert Property Owners Insurance
Company).
II. DIRECT PAYMENT AUTHORIZATION
I, hereby, authorize Company be given irrevocable power-of-attorney and my express permission to
endorse my name on any and all checks received from an insurance company on my behalf for
services provided by Company. I agree that any portion of work, deductibles, betterment,
depreciation or additional work requested by the undersigned, not covered by insurance, must be
paid by the undersigned on or before its completion. I also hereby authorize and unequivocally
instruct direct payment of any benefits or proceeds to Company.
DATED THIS _____ DAY OF _____________________, 2010, in ________, Florida
_________________________________
(Print Name) Owner/Agent
______________________________________
Address
_________________________________
(Signature) Owner/Agent
______________________________________
Phone