Insurance Law Intake Form

Name

Date of Birth

Spouse's Name

Date of Birth

Street Address

City

County

State

Zip

State of Residence

Phone Number

Business Phone

Cellular or Pager

Email Address

Best way to reach you:
Email  Phone 

Best time of day to reach you

Type of Insurance You Own

Insurance Companies You have Insurance Policies With

Do you have copies of your insurance policy(ies)?
Yes  No 

Have you read/are you familiar with your insurance policy(ies)?
Yes  No 

Are you familiar with the procedures for filing a claim with your insurance carrier?
Yes  No 

To the best of your knowledge, did you follow these guidelines when submitting your claim to the insurance company?
Yes  No 

Have you recently filed a claim with an insurance company?
Yes  No 

If Yes, Which company?

What type of claim?

Name of insurance agent you spoke with?

Date of Loss:

Date you filed your claim:

Was your claim denied?
Yes  No 

If No, were you informed of the reasons why the claim was denied?
Yes  No 

If Yes, why was the claim denied?

Are you concerned that your claim was wrongfully denied or that the insurance company acted in bad faith? Explain.

Have you received any settlement offers, communication from, or monetary checks from your insurance company as a result of filing your claim?

If you have not recently filed a claim with your insurance company, are you interested in filing a claim?
Yes  No 

What type of claim?

Name of insurance agent you have worked with, (if applicable)

How did you out about find us?

If somebody referred you to us, who was it?

Areas of Special Concern?

Are there any other issues we can assist you with?

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