Claim Investigation Authorization

Complete and sign the authorization below to allow FLC Insurance Services to investigate your claim or policy matter.

First Name *

Last Name *

Date of Birth *

Email Address *

Policy Number *

This will be inserted into the authorization below.

Authorization

I authorize FLC Insurance Services, Inc., through its Compliance Manager, licensed agent of record, and other authorized personnel with a legitimate need to know, to receive, review, securely maintain, and disclose the limited claim and medical information I provide for the purpose of investigating the enrollment and coverage associated with Policy __________, communicating with Allstate Health Solutions and Integon Indemnity Corporation, and assisting with any policy-correction request, claim reconsideration, or appeal. This authorization does not permit use of my medical information for marketing or any purpose unrelated to this matter. I understand that I may revoke this authorization in writing, except to the extent that FLC Insurance Services or another authorized party has already acted in reliance upon it.

Upload Supporting Documents

Upload any documents related to your claim or policy matter (PDF, DOCX, JPEG, PNG, GIF, CSV, XML, etc.).

Click to upload or drag files here

PDF, DOCX, images, CSV, XML up to 25MB each

Signature (type your full name) *

Must match your full name above.

Date *

By signing and submitting this form, you acknowledge that your IP address will be recorded for security and verification purposes. Your information will be securely maintained and used only for the purpose described in the authorization above.