Law Offices of Bourhis & Mann
Online Question Submittal Form
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My Question - Printable Form Please fill out and submit this form. The areas marked "required" must be completed before we can assist you. Please be sure your full name appears on each printed page before sending. This form may be sent by postal mail, or fax, or used to collect information prior to calling us. |
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| Telephone: 800.264.2082 | FAX: 415.421.0259 | |
| Address: Law Offices of Bourhis & Mann 1050 Battery Street, San Francisco, CA 94111 |
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| Personal Information: | ||
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First and Last Name
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Work Phone
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Home Phone - Other phone
(at least one phone # is required) |
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Email Address - Required
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Mailing Address:
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My Question involves:
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Type of Insurance
Required : |
Homeowner Automobile Uninsured Motorist / Underinsured (Motorist) Health Disability Life Commercial General Liability Directors and Officers Errors and Omissions Other (Describe: ) |
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If health, life or disability, was your insurance obtained through employer? Yes No |
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If so, are you employed by a private company (as opposed by being employed by the government or a religious organization)? Yes No |
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Insurance Information.
This information is required in order to assist you.
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Name of Insurance Company
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Dates of Coverage
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Years Policy in Effect
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Applicable Policy Limits
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My Question is:
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| If your claim is a disability claim, please provide the following additional information: | ||
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When you bought the policy,
what
State were you living in? |
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What is the nature of your
disability?:
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What was your occupation when
you became disabled?:
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What is your monthly benefit
amount and duration of payments (Age 65 or life)?:
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(COLA) Do you have a cost of living adjustment?
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Date and reason of termination.
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Did you obtain your policy individually or at work? If latter, please include your place of employment.:
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| For other types of insurance, please describe your issue: | ||