I hereby authorize any physician, medical practitioner, hospital, clinic, veterans
administration facility, medical information service including Medical Information
Bureau, Inc., urgent care facility, other medically related facility or entity,
insurance or reinsurance, or Consumer Reporting Agency having information available
as to diagnosis, treatment and prognosis with respect to any physical or mental
condition including drug or alcohol abuse, and/or treatment of me or my dependents
and other non-medical information of me, to release to Underwriters at Lloyds, London,
and/or International Specialty Insurance Services, Inc., or its designee any and
all such information. This authorization includes release of information concerning
psychiatric/psychological conditions and preparation of an investigative consumer
report.
I understand that the information obtained by use of the authorization will be used
by Underwriters at Lloyds, London, and/or International Specialty Insurance Services,
Inc., to determine eligibility for insurance or to determine eligibility for benefits
under the Policy. Any information obtained will not be released by the Insurer except
to reinsuring companies, insurance support organizations or other person or organizations
performing business or legal services in connection with my application, or as may
be otherwise lawfully required.
I know that I may request to receive a copy of this authorization. I know that I
may request to be interviewed if any investigative consumer report is prepared in
connection with this application. I agree that a photographic copy of this authorization
shall be as valid as the original. This authorization shall be valid for twenty-six
(26) months from the date signed.