1. FBIC should investigate Bad-faith or Unfair Insurance Claims Practices by the following Insurance Company:

Click to Select Insurance Carrier Aetna AIG Allstate American Family Assurant Blue Cross-Blue Shield Cigna CNA Coventry Equitable Farmers GEICO Hartford Hartford-AARP HealthNet Humana Kaiser Permanente Liberty Mutual MetLife Nationwide Northwestern Mutual Progressive Prudential State Farm Travelers United Healthcare UnumProvident UnumProvident Reassessment Wellpoint Zurich Other

If other, please identify:

2. The nature of the bad-faith insurance allegation in reference is related to the following coverage:

Click to Select Automobile Insurance Business Insurance Computer/Intellectual Property Insurance Disability Insurance Environmental Insurance Fire Insurance Health-Autism Insurance Health Insurance Home Insurance Life Insurance Personal Injury & Accident Insurance Professional Malpractice Property & Casualty Insurance Theft Insurance Title Insurance Workers Comp Insurance Wrongful Death Other

If other, please identify:

3. Did you ever submit a claim to the Insurer in question?

Click to Select Yes No

4. Were you denied coverage?

Click to Select Yes No Not Applicable

5. The Claim is a result of:

Click to Select Accident Death Environmental Fire Flood Health-Autism Health Liability Nature/Act of God Personal Injury Professional Malpractice Theft Vandalism Other

If other, please identify:

6. Did the Insurance Company, to your knowledge, conduct a thorough and objective investigation?

Click to Select Yes No

7. Were you asked to submit to an in-person examination under oath?

Click to Select Yes No

If Yes, were there any problems or irregularities providing it?

Click to Select Yes No

8. Were you asked to provide a written sworn statement?

Click to Select Yes No

If Yes, were there any problems associated with providing your sworn statement?

Click to Select Yes No

9. Did you discover any misconduct or wrongdoings on behalf of the Insurance Company?

Click to Select Yes No

If Yes, misconduct or wrongdoing(s) allegedly were committed on behalf of the Insurance Company by the following:

	Agency
	Consultant
	Employee/Claims Administrator
	Adjuster
	Investigator
	Attorney
	Other

10. How did you find out about the misconduct or wrongdoing?

Click to Select Insurance Company Agent Adjuster Attorney Other

If other, please identify:

11. When (approximately) did you initially discover this insurance company related misconduct?

(Month/Year):

12. Please provide the approximate date of the last bad-faith occurrence to your knowledge by the Insurance Carrier.

(Month/Year): 

13. The Insurance Company exhibited Bad-faith, misconduct or wrongdoing and/or committed an Unfair Insurance Claims Practice by acting accordingly:

(Please check all that are applicable)

	a.	Failing to acknowledge and act with reasonable promptness upon communications with respect to claims arising under insurance policies.
	b.	Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies.
	c.	Refusing to pay claims without conducting a reasonable investigation based upon all available information.
	d.	Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed.
	e.	Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear.
	f.	Compelling Insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such Insureds.
	g.	Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application.
	h.	Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of the Insured.
	i.	Making claims payments to Insureds or beneficiaries not accompanied by statements setting forth the coverage under which the payments are being made.
	j.	Making known to Insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration.
	k.	Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information.
	l.	Failing to promptly settle claims, where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
	m.	Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement.
	n.	Using as a basis for cash settlement with a first party automobile insurance claimant an amount which is less than the amount which the insurer would pay if repairs were made unless such amount is agreed to by the Insured or provided for by the insurance policy.

14. Did you ever take legal action against the Insurance Company?

Click to Select Yes No

15. Was the Insurance Company requested to authorize or make payment regarding a temporary remedy covered by your Insurance Policy?

Click to Select Yes No

If Yes, did they make payment?

Click to Select Yes No

16. How much is your claim? (approximate):

Select Range Less than $1,000 $1,000-$4,999 $5,000-$9,999 $10,000- $19,999 $20,000-$39,999 $40,000-$69,999 $70,000-$99,999 $100,000-$149,999 $150,000 -$199,999 $200,000-$299,999 $300,000-$499,999 $500,000-$749,999 $750,000-$999,999 $1,000,000 plus

17. Are you Interested in participating with other FBIC members if legal action is taken in your State against your Insurer?

Click to Select Yes No

18. Can we reference or use your specific case?

Click to Select Yes No

(Please note: Address information will be kept confidential on referenced stories.)

19. Public Relations and Press in bringing attention to the Bad-faith Insurer in question (i.e. to win public opinion and persuade existing policyholders to cancel and switch insurance to another Insurer) is an important part of FBIC's strategy. Would you be interested in participating in a brief demonstration(s) in front of the Insurance Company's or its Agent's office nearest you?

Click to Select Yes No Maybe

20. Tell Us Who You Are and How We Can Contact You:

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FBIC asks you for your support! FBIC is a (501)(c)(3) IRS tax-exempt non-profit organization. FBIC incurs substantial expense in its mission to rank, expose and stop bad faith insurance companies from harming you and yours. FBIC asks you for your tax-deductible donation and support of its mission! Thank you for your consideration.

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I represent to the best of my knowledge that the answers and information I have provided herein are truthful.

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