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Policy Review Authorization

Date
MM slash DD slash YYYY
Name of Insurance Company
First
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy #
Name of Insured
First Last
Name of Policy Owner
First Last
Date of Birth
MM slash DD slash YYYY
SS#
Please accept this letter as authorization for the below named individual/firm to be provided with any and all information regarding the above referenced policies, including current in-force ledgers.
Agent: Katie Weibel & Julianne Lepo / Specific Solutions, 475 International Drive, Williamsville, NY 14221 - Fax: 716-632-6051
*
- I authorize Katie Weibel & Julianne Lepo / Specific Solutions to obtain any and all information, including in-force ledgers.