How to fill out this form.
  1. Check a release to option and type in the required field.
  2. Click the "Print" button and sign the form.
  3. Upload, fax, drop off or mail the form to us.

Note: Document will be processed within 3 business days after it has been received.

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AUTHORIZATION TO RELEASE

INFORMATION TO A THIRD PARTY

This form is optional—complete and submit this form if you would like us to release information about your claim to any person other than the customer(s) listed on the loan or have checks from your special interest-earning escrow account made payable to the contractor only. This form is not required to receive your funds.

 




 
 

Please check the appropriate box(es). *

I/We would like Chase to release information about my claim to a third party (If you check this box, only one customer's signature is required, but if possible, please provide all customers' signatures).

Name of third party:

Relationship to customer:

I/We would like the disbursement check(s) made payable to a third party only—the customer name(s) will not appear on any disbursement check(s) (If you check this box, all customers' signatures are required).

Name of third-party payee(s):

Customer's Signature: Date:

Customer's Signature: Date:



 

Once you’ve completed this form, you can scan and upload it to InsuranceClaimCheck.com/Chase, a secure, Chase-approved site. You can also return it to us by mail or fax to:


Regular Mail:

Overnight mail:

Fax:

(Free of charge from

any Chase branch)

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