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
Date
If you add your email here, a PDF copy of this form will be sent to you.
example@example.com
Should be Empty: