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Name
E-mail Address
Phone Number
Business Phone
Cellular or Pager
Address
City
State
Zip
I suspect I have been a victim of bad faith insurance practices because:
Name, address and phone number of any contacts you may have spoken with at the insurance company.
When did your insurance loss occur?
Why do you feel your loss is covered?
Do you have any evidence that the insurer acted without following customary claim practices?
Do you have records that indicate the insurer acted in a mean or malicious manner?Yes No If yes, please list
Do you have any additional information or concerns?
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