Complete this form only if you believe you have a claim that CGLIC or its agent misrepresented the terms of your policy to you and you wish to participate in the Alternative Dispute Resolution procedure ("ADR Procedure")
If you need help or have questions about the claim form, call the following toll free number: 1 (800) 607-5556.
Your completed claim, including all the information and documents specified below, MUST BE POSTMARKED BY JULY 12, 1997 AND MAILED TO THE FOLLOWING ADDRESS:
CGLIC CLAIM REVIEW TEAM
900 COTTAGE GROVE ROAD
HARTFORD, CONNECTICUT 06152-2203
CLAIMS POSTMARKED AFTER JULY 12, 1997 WILL BE DENIED AND NOT CONSIDERED. If you do not supply all the information or documents required, your claim may be denied or the remedy you receive may be adversely affected. If you wish to submit claims with respect to more than one policy, you must submit a separate form for each policy.
I. POLICY INFORMATION
Name of Policy Owner Filing Claim:
Social Security Number:
Name of Insured:
Policy Issue Date:
Name of Agent who sold the policy:
Location where policy was sold:
II. STATEMENT OF CLAIM
Please provide a full written explanation of your misrepresentation claim. Provide as much detail as possible as to the time, location, content, and nature (oral, written, or both) of any alleged misrepresentation made in connection with your policy. Please indicate who made the misrepresentation, who was present, what was said or written, and any other information in your possession relating to that claim.
In describing the communications relating to your claim, please indicate what you were told and what documents you received before you signed an application to buy your policy. Indicate whether you were given or shown an illustration, ledger, or written explanation of policy performance and, if so, what was said about it. Please submit with your claim form a copy of each documents you were given. If your claim relates to the number of the premiums you would be required to pay, please describe what, if anything, you recall being said and what documents, if any, you received relating to that subject.
Please also tell us what documents or information you were given after you had applied for coverage, including documents or information provided at the time your policy was delivered to you. For example, were you given an illustration, ledger, or written explanation of policy performance with your policy? Did you sign a receipt? Please submit copies of any such documents with your claim form.
Please provide a description of any oral communications and copies of any written communications with the company relating to your claim.
You should also provide any other information which may assist us in evaluating your claim. You may wish to explain, for example, why you bought your policy. What purposes was it intended to serve? What were your financial needs at the time?
III. DOCUMENTS RELATED TO YOUR POLICY OR CLAIM
The explanation of your statement of claim in Section II above identifies some of the types of documents which must be submitted with your claim form. You may well have other relevant documents as well.
You must submit with your claim form copies of all documents in your possession, custody or control which relate to the sale of your policy or to your claim, regardless of whether those documents support your claim or tend to disprove your claim. You must also provide to the best of your ability a full description of any documents which you have seen which relate to your claim but which you do not currently possess or control.
IV. YOU MUST CERTIFY THAT YOUR CLAIM IS COMPLETE AND CORRECT.
You must certify that the claim information you provide is true and correct. Read carefully the foregoing description of the documents and information required. Then read carefully the following declaration before you sign your claim.
I declare, under penalty of perjury, under the laws of the United States of America (1) that the facts set forth in support of this claim, including the statements on this claim form and in the attached description of my claim, are true and correct; (2) that I have provided to the best of my ability all material information I have regarding my policy and claims; and (3) that I have provided true and correct copies of all documents in my possession, custody or control which are relevant to my policy and claim, including any documents which tend to disprove or do not support my claim as well as those that support it.
Executed on this __________ day of ___________, 199____.
Please print your name.