Limited Power of Attorney

Insured First Name:*

Insured Last Name:*

Date of Birth:*

Month/Day/Year

10-Digit Individual NPI #*

Insured Email*

Parent Company (If different from franchisee)

Company Name:

DBA (if different):

Address

Contact Name:

Phone Number:

Franchisee or Other Corporation

Company Name:

DBA (if different):

Address

Contact Name:

Phone Number:

APPOINTMENT:

Named Insured:*

Attorney-in-Fact:*

I, (named insured), do hereby appoint (attorney-in-fact) to act in my capacity as my attorney-in-fact, and grant them the authority to act in any reasonable and necessary manner for the purpose of exercising the following powers.

Power Granted:

Premium Billing: To receive invoices and make payments on my professional liability insurance policy.

Premium Refund: To request and receive premium refunds due to Policy Changes and/or overpayments.

Access to Documents: To have access to my professional liability insurance policy documents and claim history.

Policy Changes: To request changes to my policy, such as adding Certificate of Insurance holders, billing address changes, certain changes in coverage, etc. This does not include the ability to cancel a policy.

HIPAA Release: I intend for and do direct that my attorney‐in‐fact appointed in this document be treated as I would be with respect to my rights regarding the use of any medical records. I agree that when you receive a copy of this power of attorney, you may act relying on it and I waive all confidentiality restrictions with regard to allowing my attorney‐in‐fact to review any policy coverage, premium or claims information necessary to fulfill the duties listed above.

The rights, power, authority of my attorney-in-fact to exercise any and all of the rights and power listed above shall commence and be in full force and effect beginning the date chosen below, and shall remain in full force throughout the term of my professional liability insurance coverage with you unless rescinded in writing earlier by either party.

Effective Date:*

Month/Day/Year

Insured Signature:*

Today's Date:*

Month/Day/Year

By entering an electronic signature here, you acknowledge and agree that your electronic signature is the legal equivalent of a written signature on this form and that your electronic signature on this form is as valid as if you physically signed the document in writing.