AUTHORIZATION AND CONSENT
FOR DISCLOSURE BY MY INSURER OF CLAIM-RELATED INFORMATION TO THE CALIFORNIA LEGISLATURE AND STATE SENATE INSURANCE COMMITTEE SUBJECT TO SUBDIVISIONS (j) AND (k) OF GOVERNMENT CODE SECTION 9075
To further the review of my homeowners’ insurance claim, I ______(print your name), a policyholder of ______(the insurance company, and otherwise referred to herein as my insurer) under policy number ______, hereby authorize my insurer to disclose to the California Legislature and the Senate Insurance Committee, and discuss, any and all information, (including personal and privileged information as defined in Insurance Code Section 791.02-see reverse side), regarding the facts, circumstances and handling of my insurance claim (s) arising out of the 2003 wildfire disaster, and concerning my property located at: ______(please print your home’s address)
______(city), CA ______(zip).
Complete mailing address:______.
Daytime phone number:______Evening number:______
E-mail (if any):______
This consent and authorization is valid until revoked or for a period of one year from the date of signature unless otherwise revoked. I understand that the Legislature and Senate Insurance Committee will hold all personal information and privileged information as defined in section 791.02 of the Insurance Code as confidential and will not disclose such information to any party, including authorized representatives of the news media, without my prior written consent.
______
Signature of policyholder/claimant Print name
Date signed:______
Notice: Persons signing this authorization form are entitled to retain a copy.
You may also mail this form to: State Senate Insurance Committee, State Capitol, Sacramento, CA 95814. Phone number: 916-445-0825. Contacts: Brian Perkins, Staff Director, Erin Ryan, Consultant
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You may use the space below to provide a brief description of the problem with this claim (optional):
Name of attorney (optional-please print):______Address/or city (optional):______
Insurance Code Section 791.02:
(s) "Personal information" means any individually identifiable information gathered in connection with an insurance transaction from which judgments can be made about an individual's character, habits, avocations, finances, occupation, general reputation, credit, health, or any other personal characteristics. "Personal information" includes an individual's name and address and "medical record information" but does not include "privileged information."
(v) "Privileged information" means any individually identifiable information that both: (1) Relates to a claim for insurance benefits or a civil or criminal proceeding involving an individual. (2) Is collected in connection with or in reasonable anticipation of a claim for insurance benefits or civil or criminal proceeding involving an individual. However, information otherwise meeting the requirements of this division shall nevertheless be considered "personal information" under this act if it is disclosed in violation of Section 791.13.
Government Code Section 9075. Nothing in this article shall be construed to invalidate or affect the operation of Sections 10207, 10208, 10525, and 10526 of this code, or Temporary Joint Rule 37 of the Senate and Assembly in effect on the effective date of this article, or to require the disclosure of records that are any of the following: (a) Preliminary drafts, notes, or legislative memoranda, except as provided in Section 9080. (b) Records pertaining to pending litigation to which the Legislatue is a party, or to claims made pursuant to Division 3.6 (commencing with Section 810) of Title 1, until the litigation or claim has been finally adjudicated or otherwise settled. (c) Personnel, medical, or similar files, the disclosure of which would constitute an unwarranted invasion of personal privacy, provided that the Senate Committee on Rules, the Assembly Committee on Rules, or the Joint Rules Committee shall determine whether disclosure of these records constitutes an unwarranted invasion of personal privacy. (d) Records pertaining to the names and phone numbers of senders and recipients of telephone and telegraph communications, provided that records of the total charges for any such communication shall be open for inspection. (e) Records pertaining to the name and location of recipients of automotive fuel or lubricants expenditures, provided that records of the total charges for those expenditures shall be open for inspection. (f) In the custody of or maintained by the Legislative Counsel, except those records in the public data base maintained by the Legislative Counsel that are described in Section 10248. Legislative records shall not be transferred to the custody of the Legislative Counsel to evade the disclosure provisions of this chapter. (g) In the custody of or maintained by the majority and minority caucuses and majority and minority consultants of each house of the Legislature, provided that legislative records shall not be transferred to the custody of the majority and minority caucuses and majority and minority consultants of each house of the Legislature to evade the disclosure provisions of this chapter. (h) Correspondence of and to individual Members of the Legislature and their staff, except as provided in Section 9080. (i) Records the disclosure of which is exempted or prohibited pursuant to provisions of federal or state law, including, but not limited to, provisions of the Evidence Code relating to privilege. (j) Communications from private citizens to the Legislature, except as provided in Section 9080. (k) Records of complaints to or investigations conducted by, or records of security procedures of, the Legislature.
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