Insurance Questionnaire

Blady Weinreb Law Group LLP
Commitment - Reputation - Results

COMMITMENT-REPUTATION-RESULTS ©

Insurance Bad Faith Questionnaire

The following questionnaire is requested for an initial evaluation of an insurance or insurance bad faith claim. The submission of information is for review only. BWLG is not agreeing to accept your case by reviewing this questionnaire. BWLG is not your attorney unless and until a written Retainer Agreement is signed by both you and a member of the firm.

It takes time to review the material submitted and to reply. If you do not receive a response within 1 week, please accept the non-response as an indication we are unable to accept your case.

The information you provide to us is for the purposes of obtaining advice and therefore we consider the informtion subject to the attorney-client privilege, even prior to us agreeing to accept your case.

Insurance Law Questionnaire

Your Name
Your Address
Street (Apartment No,)
City
State
Zip
E-Mail
Home Phone Number Cell Phone Number
Name of Your Insurance Company What Type of Insurance (Eg., Health, HMO, Disability, Life, Auto, Business, Property) Does the Claim Relate to Insurance Provided by Your Employer or is it an Individual Policy?
Date of Injury or Insured Event Date You Made a Claim for Insurance Benefits Date of Denial of Your Claim or Part of Your Claim
Location of Injury, Accident or Other Insured Event (Include City/State)
Please Describe the Facts That You Believe Create Insurance Coverage? (Include the Who, What, When, Where and How)	.
Desribe Your Damage Do You Have Documentation of the Damages You Have Suffered? If so, Please Describe the Documentation.
Did You Have a Complete Copy of the Policy You Believe Provides You Insurance Coverage:

Blady Weinreb Law Group LLP
6310 San Vicente Boulevard, Suite 400
Los Angeles, California 90048
(323) 933-1352
FAX (323) 933-1353