I / We confirm that the facts stated in this form to be true and accurate to the best of My / Our knowledge. I / We understand that the information provided in relation to this claim may be shared with other insurers or financial institutions for the purposes of dealing with this claim and eliminating insurance fraud. I / We give authority to the insurers and their representatives to contact My / Our Medical Practitioners for any additional information.
I / We confirm that I / We give authority for you to approach any third party who holds information relating to the incident giving rise to this claim, I / We hereby authorise any such third party to release such information to you to assist in the investigation and resolution of My / Our claim.
I / We hereby grant Collinson (as agent for the underwriter) full rights of subrogation in respect of any payments made on My / Our behalf. I / We further agree to fully co-operate with any such recovery efforts from liable third party or parties.
Please note that if you do not authorise your agent / third party to deal with the claim, we will not be able to discuss any details of the claim with them due to Data Protection Act regulations.