Obtaining a precise quote necessitates your loss runs, and we acknowledge the inconvenience of requesting them from your current insurance carrier. We’re committed to easing that process for you. By endorsing this form, you grant us permission to retrieve those records directly from your current insurance carrier, alleviating the burden on your end.

This authorization form remains valid for 30 days from the date of submission.
Company name of insurance carrier
Please provide the policy number
Enter the expiration date of the policy.
Authorization: I authorize Go Further Group to contact and communicate with my current insurance carrier listed in this form on my behalf to request loss runs.
Confidential Information: I acknowledge that Go Further Group may need access to confidential information regarding my current insurance carrier to request the loss runs. I authorize the exchange of this information between Go Further Group and my current provider listed in this form, as required.
Liability: I release Go Further Group from any liability arising from its actions taken on my behalf to request loss runs from my current insurance carrier listed in this form.
Effective Date: This authorization form remains valid for 30 days from the date of submission.
Termination: I understand that I may revoke this authorization at any time by providing written notice to Go Further Group.
For mobile phones, and tablets use your finger to draw your signature.