EmailMe Form - Insurance Representative Report Form

Insurance Representative Report Form
This form is intended for the insurance representative or adjuster who is involved in a personal injury, general liability, professional liability or medical negligence claim. If you wish, please feel free to consult with your insured's counsel prior to filling out this form; however,we request that the answers to these questions are your personal answers.

What is your name? *

Do you have any time constraints concerning the length of the mediation? *

What do you perceive to be the strongest facts/claims for you insured? Please describe. *

What do you perceive to be your insured's biggest weaknesses? Please describe. *

In your opinion, what impediments, if any, are there to conducting a successful mediation and reaching a settlement? *

Is the insured's consent to the settlement required? *

What are the insured's policy limits?

Is the policy a "wasting" policy? If so, how much has been previously wasted? *

Have there been any previous claims that have reduced the aggregate amount under the insurance policy? If so, how much of the aggregate is remaining? *

Has a reservation of rights letter been issued? And are there any significant issues concerning coverage? If so, describe those issues? *

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