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INSURANCE ASSIGNMENT AND RELEASE Family First Medicine 1140 Charles Lane Marysville Ohio 43040 Telephone: 9375784291 I certify that I, and/or my dependent(s), have insurance coverage with. And assign
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Make copies of the filled-out form for your records.
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Submit the form to the appropriate insurance company or party as instructed.

Who needs insurance assignment and release?

01
Individuals who have been involved in an accident or incident and need to file an insurance claim.
02
People who are seeking compensation for damages or injuries through an insurance policy.
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Policyholders who are required by their insurance company to provide an assignment and release form.
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Parties involved in a settlement agreement or legal dispute that requires the completion of an insurance assignment and release form.
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Insurance assignment and release is a legal document that transfers the rights and benefits of an insurance policy to another party, typically in exchange for a settlement.
The party who is receiving the benefits of the insurance policy is required to file the insurance assignment and release.
To fill out an insurance assignment and release, you must provide your insurance policy details, as well as the details of the party to whom you are assigning the benefits.
The purpose of insurance assignment and release is to transfer the rights and benefits of an insurance policy from one party to another in a legal and binding manner.
The insurance assignment and release must include details of the insurance policy, the parties involved, the date of assignment, and the terms of the assignment.
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