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Insurance Assignment Agreement (Assignment of Benefits) Template
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Insurance Assignment Agreement (Assignment of Benefits) Template
This Insurance Assignment Agreement (Assignment of Benefits) (“Agreement”) is entered into on [Date], by and between:
Assignor / Policyholder / Insured: [Full Name]
Address: [Address]
Email: [Email]
Phone: [Phone Number]
and
Assignee: [Full Name or Business Name]
Address: [Address]
Email: [Email]
Phone: [Phone Number]
The parties agree as follows:
1. Insurance Policy and Claim Information
This Agreement relates to the following insurance policy and claim or potential claim:
Insurance Company / Insurer: [Insurance Company Name]
Policy Number: [Policy Number]
Claim Number: [Claim Number, if available]
Type of Insurance: [Health / Property / Auto / Disability / Other]
Date of Loss, Service, or Incident: [Date]
Description of Loss, Service, Repair, or Claim: [Description]
2. Assignment of Benefits
The Assignor hereby assigns to the Assignee the following insurance benefits, rights, and payment interests, to the extent allowed by applicable law and the insurance policy:
the right to receive direct payment of insurance proceeds for the following service, repair, treatment, or obligation: [Describe];
the right to submit invoices, estimates, bills, records, or supporting documents related to the assigned benefits;
the right to communicate with the insurer regarding the assigned benefits;
any other specifically assigned right: [Describe].
This assignment is limited to the benefits arising from the matter described in this Agreement unless the parties expressly state otherwise here: [State any broader or narrower scope].
3. Rights Not Assigned
Except as expressly stated in this Agreement, the Assignor does not assign ownership of the insurance policy or any unrelated claim rights.
The following rights are specifically not assigned, if applicable:
rights unrelated to the assigned loss, service, repair, or treatment;
personal claims for bad faith, punitive damages, emotional distress, or other extra-contractual relief unless expressly allowed by law and specifically assigned here: [Describe if any];
any right that cannot legally be assigned.
4. Purpose of Assignment
The purpose of this Agreement is to allow the Assignee to receive insurance benefits or claim-related payment directly, or to pursue payment for the goods, services, repairs, treatment, or work provided to the Assignor.
This Agreement does not require the insurer to pay more than is owed under the policy and does not expand coverage beyond the policy’s terms.
5. Assignor Representations
The Assignor represents that:
the Assignor is the insured, policyholder, beneficiary, claimant, or other person with authority to assign the benefits described in this Agreement;
the information provided in connection with the insurance policy and claim is true and correct to the best of the Assignor’s knowledge;
the Assignor has not previously assigned the same benefits in a way that would conflict with this Agreement, except as disclosed here: [Describe or state “None”].
6. Assignee Responsibilities
The Assignee agrees to use the assigned benefits only in connection with the matter described in this Agreement.
The Assignee will:
apply any insurance payment received to the goods, services, repairs, treatment, or charges covered by this Agreement;
provide reasonable documentation supporting the amount claimed, if requested;
comply with applicable law in seeking payment or communicating with the insurer.
The Assignee does not guarantee that the insurer will approve, cover, or fully pay the assigned benefits.
7. Payment Application and Excess Proceeds
Any insurance payment received by the Assignee will be applied first to the Assignee’s lawful charges relating to the assigned matter.
If the Assignee receives insurance proceeds exceeding the amount lawfully owed to the Assignee for the assigned matter, the excess amount will be handled as follows:
☐ returned to the Assignor within [Number] days;
☐ applied according to separate written instructions;
☐ handled as follows: [Describe].
8. Assignor Cooperation
The Assignor agrees to reasonably cooperate with the Assignee in connection with the assigned benefits, including by:
signing additional documents reasonably necessary to support the claim;
providing requested records, photos, receipts, invoices, or other supporting information;
responding to reasonable insurer inquiries related to the assigned benefits.
The Assignor is not required to cooperate beyond what is lawful or reasonably necessary.
9. No Guarantee of Coverage or Payment
The parties understand that this Agreement does not guarantee insurance coverage, claim approval, or payment by the insurer.
All assigned rights remain subject to:
the terms, conditions, exclusions, and limits of the insurance policy;
insurer investigation, adjustment, and coverage determination;
applicable law and any non-assignability rule that may apply.
10. Revocation
This assignment is:
☐ revocable by the Assignor before payment is made and before the Assignee materially relies on the assignment, to the extent allowed by law;
☐ irrevocable once signed, to the extent allowed by law;
☐ subject to the following revocation terms: [Describe].
Any attempted revocation must be made in writing and delivered to the Assignee and, if appropriate, to the insurer.
11. No Waiver of Other Obligations
Unless expressly stated otherwise, this Agreement does not waive any deductible, copayment, coinsurance, uncovered amount, or other personal financial obligation of the Assignor that may exist under the policy or under a separate service, treatment, or repair agreement.
Any separate payment arrangement between the Assignor and the Assignee is as follows: [Describe or state “None”].
12. Indemnification
To the extent permitted by applicable law, the Assignor agrees to be responsible for losses arising from false statements or lack of authority to make the assignment.
To the extent permitted by applicable law, the Assignee agrees to be responsible for the Assignee’s own acts, omissions, billing practices, and use of assigned benefits.
13. Governing Law
This Agreement will be governed by the laws of [State/Country], without regard to conflict of law principles.
14. Entire Agreement
This Agreement represents the entire understanding between the parties regarding the assignment of the insurance benefits described above and supersedes prior oral or written discussions on the same subject.
Any amendment to this Agreement must be in writing and signed by both parties.
15. Signatures
Assignor / Policyholder / Insured
Signature: __________________________
Name: [Full Name]
Date: [Date]
Assignee
Signature: __________________________
Name: [Full Name]
Title: [Title, if applicable]
Date: [Date]
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Insurance Assignment Agreement (Assignment of Benefits) Template
Insurance Assignment Agreement (Assignment of Benefits) Template FAQ
What is an insurance assignment agreement?
An insurance assignment agreement, often called an assignment of benefits or AOB, is a document in which a policyholder transfers certain insurance claim rights or policy benefits to a third party. In practice, this can allow the assignee to seek payment directly from the insurer and, depending on the wording and applicable law, communicate with the insurer about the assigned claim.
Why do you need an insurance assignment agreement?
You need an insurance assignment agreement when the insured wants a provider, contractor, repair company, or similar third party to receive insurance proceeds or handle part of the claim process directly. A written agreement helps clarify what rights are being assigned, whether the assignment is limited, and how any insurance payment should be applied.
When should you use an insurance assignment agreement?
Use this document when a policyholder wants to assign eligible insurance benefits connected to a specific loss, service, repair, or claim. AOB arrangements are commonly seen in health insurance and in some property-claim situations, but whether they are allowed can depend on the type of policy and state law. For example, Florida states that certain auto-glass and ADAS assignments are void for policies issued or renewed on or after July 1, 2023.
How to write an insurance assignment agreement?
Start by identifying the assignor, the assignee, the insurer, and the insurance policy or claim. Then state exactly which benefits or payment rights are being assigned, whether the assignee may communicate with the insurer or submit claim materials, and whether the assignment is limited to a particular service, invoice, repair, or loss. It is also helpful to address excess proceeds, cooperation duties, revocation terms, and the fact that the assignment remains subject to policy terms and applicable law.
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