Insurance Rejection Notice

INSURANCE REJECTION NOTICE

Insurer Name:    Notice Date:

Insured / Applicant Information

Date of Birth:    Policy Number:    Claim Number:

Policy Details

Auto    Homeowners    Liability    Health    Life    Other:

Policy Period From:    To:    Premium:

Determination

Based on our review of the submitted materials and the policy terms, the claim identified above is hereby: Denied on the following basis:

Coverage Exclusion under policy provisions
Late notice or failure to provide timely notice of loss
Pre-existing condition or prior damage excluded by policy
Failure to cooperate or refusal to provide requested documentation
Policy lapsed or not in force at time of loss
Fraudulent or misrepresented information material to coverage
Other:

Effective Date of Denial:    Portion Denied: All    Partially

Documents Enclosed / Requirements for Appeal

Enclosed with this notice: Summary of findings    Claims file excerpt    Policy declaration page

Medical records or provider statements
Police report (if applicable)
Photographs of damage or scene
Repair or replacement estimates
Proof of loss documentation
Other:

Appeal/Request for Reconsideration Deadline:

Contact for Reconsideration

Title:    Phone:    Email:

Declaration

The undersigned certifies that this determination was made after a review of the available claim materials and policy terms, and that the reasons stated above are the basis for the denial. This notice identifies the material factual and legal grounds supporting the denial and the documentation required for reconsideration. This notice does not create new coverage beyond the terms of the policy.

By checking the box below and signing, the insured acknowledges receipt of this Insurance Rejection Notice and elects the following action:

I request reconsideration of the denial and will submit the required documentation by the appeal deadline.

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