Prime Consulting's Assignment of Rights form

Assignment of Rights

Rhode Island
Insurance Company
Claim Number
Sometimes refered to as a File Number
To Whom It May Concern:

I do hereby exercise my "Motor Vehicle Appraisal Provision" for the claim number listed above. Furthermore, I assign and appoint Doug Begin of Prime Consulting Services LLC as my disinterested independent appraiser to represent my interests in the matter.
Name

First NameLast Name
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you add your email here, a PDF copy of this form will be sent to you.
example@example.com
Should be Empty: