I. ASSIGNMENT OF INSURANCE BENEFITS

I, hereby, assign any and all insurance rights, benefits, proceeds and any causes of action under any applicable insurance policies to T.A.C.T. (hereinafter referred to as “Company”), for services rendered, or to be rendered by Company. In this regard, I waive my privacy rights. I make this assignment in consideration of Company’s agreement to perform services and supply materials and otherwise perform its obligations under this contract, including not requiring full payment at the time of service. I also hereby direct my insurance carrier(s) to release any and all information requested by Company, its representative, and/or its Attorney for the direct purpose of obtaining actual benefits to be paid by my insurance carrier(s) for services rendered or to be rendered. I believe the appropriate insurance carrier to be

II. DIRECT PAYMENT AUTHORIZATION

I hereby authorize and unequivocally instruct direct payment of any benefits or proceeds to Company. The payment of any benefits or proceeds to Company must be sent directly to Company and payment made solely to Company. I understand that I am responsible for payment for any services provided by Company for which payment is not recoverable from my insurance company, including any applicable deductible.

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IN  , Tennessee

(Print Name) Owner/Agent
(Signature) Owner/Agent
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