Insurance Release Form
Insurance release form is an official document which is initiated between an interested insurance participant and a company before participating in any kind of event and a risky task. Such a form plays a vital role in case the participant receives any injury or meets with some accident during the event.
Sample Insurance Release Form:
Personal Details of the Participant:
First Name: ___________________ Middle Name: ________________ Last Name: ______________
Date of Birth: ____/ ___/ ____
Age: __________Sex: ____
Blood Group: ___________
Permanent Address: Street No: __________ City: __________ State: _________ Country: _________ ZIP: _____________
Contact Number: _____________
Occupation: ___________________
Insurance Release Terms:
Name of the Insurance Company: ___________
Official Address: _______________________________
Phone number: _________________________________
Website: ________________________________
Is the participant agreed to purchase the insurance: ______________ yes/ no
As per the medicinal report of participant, any physical disease and mental illness is diagnosed: ___________ yes/ no
Has the participant agreed to the offered insurance coverage against accidental injuries and medical claims for this task: __________ yes/ no?
Insurance release date: _____/ ________/ ________
Signed by the Participant: _______________
Signed by the parent if the participant is minor: ___________
Signature of the concerned insurance Authority: _____________
Signed by witness 1: ___________________
Date: _____/ _________/ ________
Seal: ____________
Category: Release Forms
