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Wrongful Handling of Insurance Claim Questions

Please state the nature of your insurance claim that was wrongfully handled by your insurance company:

What do you believe is the amount of your claim?

What type of insurance policy is involved with your claim:

Automobile
Homeowners
Renters
Disability
Health
Life
Long-Term Care

When did the claim of loss occur?

When did the insurance company deny your claim?

Personal Injury Questions

On what date did the incident occur?

What type of incident occurred?

Auto accident
Slip and fall
Dog bite
Wrongful death
Other

If other please describe

What is the extent of your injuries?

If you have been treated for your injuries, what are your medical bills?

* Name

* Email

* Phone

City

State


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