Curacao Credit Shield

Personal Information
Please Select One Of The Following Events.
Please Provide More Information Regarding Your Event.
Involuntary Job Loss/Unemployment/Family Leave

Reason For Unemployment:

Type of unemployment

Are you currently registered

At a state unemployment office

At job agency

Authorization

I AUTHORIZE any employer, physician, hospital, clinic, other medically related facility, the Medical Information Bureau, Inc., consumer reporting agency, law enforcement agency, fire department, Social Security Administration, Internal Revenue Service, or other organization or person having any records, data or information concerning this claim to furnish such record, data or information to the protection company issuing my information. I understand that in executing this Authorization, I waive the right for such information to be privileged as it pertains to the processing or investigation of my claim(s). A photocopy of this authorization shall be considered as effective and valid as the original. I understand and acknowledge that this authorization extends to all or a part of the records being requested, which may include treatment for physical and mental illness, alcohol/drug abuse, and/or HIVAIDS test results or diagnosis and treatment. I expressly consent to release of information as designated above. The above information is true and correct. If, in fact, the furnished information is false, thereby inducing payments of claim, and the protection company issuing my information determines that the incorrect information constitutes an aiding and abetting the filling of fraudulent activation of protection, the protection company issuing my information may furnish the above information to the appropriate state authorities to be used in its discretion as the basis for action authorized under applicable state law. In addition, I agree any statements made on this or any other form found to be false shall give the protection company issuing my Curacao Credit Shield Plan the right to void my Curacao Credit Shield Plan. This authorization shall remain valid for the duration of the claim.
FRAUD WARNING: Any person who knowingly files a statement of claim containing any misrepresentations or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

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