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Bad Faith Insurance Claims - Greg Jones and Associates trial lawyers representing plaintiffs in long term disability insurance claims denial.

Confidential Bad Faith ClaimsLawyer Inquiry Form

If you or someone you know may have a potential personal claim, please fill out the following brief, confidential questionnaire. By submitting the information below, we will be able to contact you concerning your inquiry. We will do our best to answer but the laws differ from state to state and with the limited information on such a short form, we cannot get all the information upon which to provide legal advice upon which you should rely. Do not make any decisions on your Bad Faith case without a full legal consultation with GREG JONES, P.A. or other legal counsel. The submission of this form does not constitute an attorney-client privilege nor a request for legal advice. Since this matter may involve a different state’s laws, submission of this form agrees that local counsel may be contacted for referral of the matter.

There is no charge for this Bad Faith Litigation Legal Evaluation. If you do not wish to complete the form, you may email me at info@gregjoneslaw.com

*Note: starred fields are required.

 
*First Name:
*Last Name:
*Email:
*Phone:
State:
Date of Birth: (mm/dd/yyyy)
 
Occupation:
Name of Employer:
Nature of Disability:
Last Date of Employment: (mm/dd/yyyy)
 
What was the amount of your monthly salary?
 
Are you receiving Social Security Disability? If so, what is the monthly benefit?
 
What was or is the amount of your monthly disability benefit?
 
If receiving Social Security, what is your benefit after offset?
 
Are you receiving Workers' Compensation Benefits? If so, what is the monthly benefit?
 
Type of disability policy
 
Was the insurance premium paid by you or your company or both?
 
Who was the Insurance Carrier?
 
When did you first apply for disability?
(mm/dd/yyyy)
 
Were you denied? If so, when?
 
Reason for the denial?
 
Did the carrier send a denial letter? If so, what was the date of the letter?
 
Did the Insurance Carrier inform you of an appeal deadline? If so, what was the date of the deadline?
 
Did you appeal? If so, when?
 
Was your appeal denied? If so, when?
 
Do you have a copy of your policy?
Yes No
 
Who was the adjuster handling your claim?
 
Who was your primary doctor?
 
Were you sent for an Independent Medical Exam? If so, who was the doctor?
 
Comments:
 
 



 
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