Select Insurance Carrier from List Aetna Allstate Cigna CNA Equitable GEICO Hartford John Hancock Liberty Mutual Mass Mutual Metropolitan Life Nationwide Providian Prudential State Farm Teachers Travelers Other

If other, please identify:

2. The nature of the insurance coverage:

Select Type from List Automobile Insurance Business Insurance Computer/Intellectual Property Insurance Disability Insurance Environmental Insurance Fire Insurance Health Insurance Home Insurance Life Insurance Personal Injury & Accident Insurance Professional Malpractice Property & Casualty Insurance Theft Insurance Wrongful Death Other

If other, please identify:

3. State Located in:

Select Insurance Carrier State from List Alabama Alaska Arizona Arkansas Armed Forces - USA Armed Forces - Canada Armed Forces - Europe California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Name of Insured party (optional):

4. The approximate amount of your Claim:

Select Amount from List 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

5. Please rate the Insurer from 0 to 10 (10 being the highest, 0 being lowest):

	Was responsive and forthcoming to my request for information
	Returned phone calls promptly
	Paid claims with little delay
	Showed concern, decency and ethics in their dealings with me
	Paid the dollar amount of the claim fairly and equitably

6. Overall Rating:

Yes.  I would recommend this company to a friend
No.  I would not recommend this company to a friend

Additional Comments:

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

Email address: (required)
First Name: (required)
Middle Initial:
Last Name: (required)
Address1: (required)
Address2:
City: (required)
County: (required)
State: (required)	Click to Select Alabama Alaska Arizona Arkansas Armed Forces - USA Armed Forces - Canada Armed Forces - Europe California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip: (required)

I represent that I am not an employee nor am I related to an employee of the Good Faith Insurer that I am attesting herein. I represent to the best of my knowledge that the answers and information I have provided herein are truthful.