Filing Number: 665138
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| Filing Accepted: 12/30/2022 |
| Last/Business Name
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SMOYER
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First Name |
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ANNAMARIE |
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| Street Address
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6220 RIVER SHORE CT., |
| City, State Zip
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NORTH FORT MYERS,
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33917
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| Email Address
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DAVID@CLAIMCLOSERS.NET |
| Complainant Type:
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Insured |
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| Last/Business Name* |
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SMOYER |
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First Name |
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ANNAMARIE |
| Policy # * |
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EDH5353669-01 |
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Claim #* |
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EDI951646 |
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Attorney is Applicable
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| Insurer Type
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 Authorized Insurer
 Unauthorized Insurer
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| Insurer Name |
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| Insurer Name* |
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EDISON INSURANCE COMPANY
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| Insurer Name* |
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| Street Address* |
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| City, State Zip* |
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,
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NAIC Company Code 12482 |
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| Name of individual responsible for violation (if any):*
DESK AND FIELD ADJUSTER
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| Type of Insurance
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Residential Property & Casualty
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| Reason for Notice
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Claim Delay
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Unsatisfactory Settlement Offer
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Unfair Trade Practice
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Other
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627.70131
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Statutory provision(s) which the insurer allegedly violated.
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| 624.155(1)(b)(1) |
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Not attempting in good faith to settle claims when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her or his interests.
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| 624.155(1)(b)(3) |
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Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
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| 626.9541(1)(i)(3)(a) |
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Failing to adopt and implement standards for the proper investigation of claims.
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| 626.9541(1)(i)(3)(b) |
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Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue.
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| 626.9541(1)(i)(3)(c) |
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Failing to acknowledge and act promptly upon communications with respect to claims.
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| 626.9541(1)(i)(3)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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| 626.9541(1)(i)(3)(e) |
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Failing to affirm or deny full or partial coverage of claims, and, as to partial coverage, the dollar amount or extent of coverage, or failing to provide a written statement that the claim is being investigated, upon the written request of the insured within 30 days after proof-of-loss statements have been completed.
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| 626.9541(1)(i)(3)(f) |
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Failing to promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement.
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| 626.9541(1)(i)(3)(g) |
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Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
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| 626.9541(1)(i)(3)(h) |
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Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
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| 626.9541(1)(i)(3)(i) |
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Failing to pay personal injury protection insurance claims within the time periods required by s. 627.736(4)(b).
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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
Addtl Violations:
Florida Admin Code:
69B-220.201(3)(b) An adjuster shall treat all claimants equally.
69B-220.201(3)(b)2. An adjuster shall adjust all claims strictly in accordance with the insurance contract.
69B-220.201(3)(c) An adjuster shall not approach investigations, adjustments, and settlements in a manner prejudicial to the insured.
69B-220.201(3)(e) An adjuster shall handle every adjustment and settlement with honesty and integrity, and allow a fair adjustment or settlement to all parties without any remuneration to himself except that to which he is legally entitled.
69B-220.201(3)(j) An adjuster shall not knowingly fail to advise a claimant of the claimant's claim options in accordance with the terms and conditions of the insurance contract.
69B-220.201(3)(k) An adjuster shall not undertake the adjustment of any claim concerning which the adjuster is not currently competent and knowledgeable as to the terms and conditions of the insurance coverage, or which otherwise exceeds the adjuster's current expertise
69J-166.031 Selectively and detrimentally choosing which alternative dispute resolution to utilize.
Relevant Policy Language:
Governed by the cited authorities, the subject policy provides coverage for sudden and accidental losses and damages arising from Hurricane Ian. The loss payment provision and governing law provides that the insurer has a fiduciary duty to in good faith promptly investigate, adjust, and issue payment of the undisputed amount of the loss and damages. Furthermore, the policy provides coverage for, inter alia, assessments in relation to remediation, as well as the amount necessary to perform remediation.
A. Coverage A – Dwelling and Coverage B – Other Structures.
We insure against direct physical loss to property described in Coverages A and B.
We do not insure, however, for loss:
1. Excluded under Section I – Exclusions;
2. Involving collapse, including any of the following conditions of property or any part of the property,
whether above or below the ground:
a. An abrupt falling down or caving in;
b. Loss of structural integrity, including separation of parts of the property or property in danger of falling
down or caving in; or
c. Any spalling, crumbling, cracking, shifting bulging, racking, sagging, bowing, bending, leaning,
settling, shrinkage or expansion, or any other age or maintenance related issues, as such condition
relates to (1) or (2) above.
except as provided in E.8. Collapse under Section I – Property Coverages; or
3. Caused by:
a. Freezing of a plumbing, heating, air conditioning or automatic fire protective sprinkler system or of a
household appliance, or by discharge, leakage or overflow from within the system or appliance
caused by freezing. This provision does not apply if you have used reasonable care to:
(1) Maintain heat in the building; or
(2) Shut off the water supply and drain all systems and appliances of water.
However, if the building is protected by an automatic fire protective sprinkler system, you must use
reasonable care to continue the water supply and maintain heat in the building for coverage to apply.
For purposes of this provision, a plumbing system or household appliance does not include a sump,
sump pump or related equipment or a roof drain, gutter, downspout or similar fixtures or equipment;
b. Freezing, thawing, pressure or weight of water or ice, whether driven by wind or not, to a:
(1) Fence, pavement, patio or swimming pool;
(2) Footing, foundation, bulkhead, wall, or any other structure or device that supports all or part of a
building, or other structure;
(3) Retaining wall or bulkhead that does not support all or part of a building or other structure; or
(4) Pier, wharf or dock;
c. Theft in or to a dwelling under construction, or of materials and supplies for use in the construction
until the dwelling is finished and occupied;
d. Vandalism and malicious mischief, and any ensuing loss caused by any intentional and wrongful act
committed in the course of the vandalism or malicious mischief, if the dwelling has been vacant for
more than 30 consecutive days immediately before the loss. A dwelling being constructed is not
considered vacant;
e. Accidental discharge or overflow of water or steam; unless loss to property covered under Coverage
A or B results from an accidental discharge or overflow of water or steam from within a plumbing,
heating, air conditioning or automatic fire protective sprinkler system or household appliance on the
"residence premises."
Loss to property covered under Coverage A or B that results from an accidental discharge or
overflow of water or steam from within a plumbing, heating, air conditioning or automatic fire
protective sprinkler system or household appliance on the “residence premises” includes the cost to
tear out and repair only that part or portion of the building, or other structure covered under Coverage
A or B, on the "residence premises," necessary to access the system or appliance.
The cost that we will pay for the tear out and repair of the part or portion of the building or other
structure covered under Coverage A or B as specified above is limited to only that part or portion of
the covered building or other structure which is necessary to provide access to the part or portion of
the system or appliance that caused the covered loss, whether the system or appliance or any part or
portion of the system or appliance, is repairable or not.
In no event will we pay for the repair or the replacement of the system or appliance that caused the
covered loss.
We do not cover loss:
(1) To the system or appliance from which this water or steam escaped;
(2) On the “residence premises” caused by accidental discharge or overflow which occurs off the
“residence premises”;
(3) Caused by constant or repeated seepage or leakage of water or steam or the presence or
condensation of humidity, moisture or vapor, over a period of weeks, months or years, unless
such seepage or leakage of water or the presence or condensation of humidity, moisture or vapor
and the resulting damage is unknown to all "insureds" and is hidden within the walls or ceilings or
beneath the floors or above the ceilings of a structure;
(4) To a plumbing system, whether above or below the ground, caused by:
(a) Age, collapse, obsolescence, wear, tear;
(b) Fading, oxidization, weathering;
(c) Deterioration, decay, marring, delamination, crumbling, settling, cracking;
(d) Shifting, bulging, racking, sagging, bowing, bending, leaning;
(e) Shrinkage, expansion, contraction, bellying, corrosion;
(f) The unavailability or discontinuation of a part or component of the system; or
(g) Any other age or maintenance related issue;
(5) To a plumbing system, whether above or below the ground, caused by the impairment, state or
condition of the system, which prohibits repair or replacement including access, necessary to
connect the adjoining parts of appliances, pipes or system; or
(6) Loss otherwise excluded or limited elsewhere in the policy.
For purposes of this provision, a plumbing system or household appliance does not include a sump,
sump pump, irrigation system or related equipment or a roof drain, gutter, down spout or similar
fixtures or equipment.
f. Any of the following:
(1) Wear and tear, marring, deterioration, decay;
(2) Mechanical breakdown, latent defect, inherent vice or any quality in property that causes it to
damage or destroy itself;
(3) Smog, rust or other corrosion;
(4) Smoke from agricultural smudging or industrial operations;
(5) Discharge, dispersal, seepage, migration, release or escape of pollutants unless the discharge,
dispersal, seepage, migration, release or escape is itself caused by a Peril Insured Against
named under Coverage C.
Pollutants means any solid, liquid, gaseous or thermal irritant or contaminant, including smoke,
vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled,
reconditioned or reclaimed;
(6) Settling, shrinking, bulging or expansion, including resultant cracking, of bulkheads, pavements,
patios, footings, foundations, walls, floors, roofs or ceilings;
(7) Birds, rodents or insects;
(8) Nesting or infestation, or discharge or release of waste products or secretions, by any animals; or
(9) Animals owned or kept by an "insured".
If any of these cause water damage not otherwise excluded or limited elsewhere in the Policy, from a
plumbing, heating, air conditioning or automatic fire protective sprinkler system or household
appliance, we cover loss caused by the water including the cost to tear out and repair only that part or
portion of the building or other structure covered under Coverage A or B, on the “residence premises”
necessary to access the system or appliance.
The cost that we will pay for the tear out and repair of the part or portion of the building or other
structure covered under Coverage A or B as specified above is limited to only that part or portion of
the covered building or other structure which is necessary to provide access to the part or portion of
the system or appliance that caused the covered loss, whether the system or appliance, or any part
or portion of the system or appliance, is repairable or not.
In no event will we pay for the repair or the replacement of the system or appliance that caused the
covered loss.
We do not cover loss to the system or appliance from which this water or steam escaped.
For purposes of this provision, a plumbing system or household appliance does not include a sump,
sump pump, irrigation system or related equipment or a roof drain, gutter, downspout or similar
fixtures or equipment.
Section I – Exclusion A.3. Water, Paragraphs a. and c. that apply to surface water and water below the
surface of the ground do not apply to loss by water covered under 3.e. and f. above.
Under 2. and 3. above, any ensuing loss to property described in Coverages A and B not excluded or
otherwise precluded by any other provision in this Policy is covered.
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Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
The Complainant and insured, Annamarie Smoyer (collectively referred to as “Complainant”), maintained a homeowner’s policy of insurance (“Policy”) with Edison Insurance Company (“INSURER”) which provided coverage for their sudden and accidental damages and losses resulting from Hurricane Ian (“Loss”). The Loss caused substantial, direct and consequential damages, and INSURER’s general business practice of willful, wanton, immoral, deceptive and bad faith claim handling policies, procedures, guidelines, protocol, adjusting, investigating, drawing valuations and issuing payment for the claims has caused the Complainant to suffer further harm and extra-contractual damages which have accrued, and will continue to accrue. The stated misconduct is collectively referred to as “Bad Faith,” and the specific factual and/or legal considerations in relation thereto are further outlined below for their consideration in accordance with Fla. Stat. Sec. 624.155 and the cited legal authorities associated therewith.
1.) INSURER insures thousands of homes throughout Florida wherein the Complainant’s residence is located. That said, and even though INSURER knows that it has a fiduciary duty to its insureds whose residences are located in a high-risk zone for hurricane damages, it failed to institute the necessary policies, procedures, guidelines, protocol, personnel and contingencies in relation to fully, promptly and equitably indemnifying its insureds who were affected in mass by the devastating and widespread impact of Hurricane Ian. Consequently, insureds such as the Complainant were forced to: fend for themselves to mitigate damages arising from INSURER’s Bad Faith; incur out of pocket expenses that INSURER was required to afford pursuant to the Policy; absorb the burden, expense, inconvenience and delay associated with an insurer who was not equipped (because they didn’t want to incur the expense associated therewith) to meet their contractual obligations; risk health hazards associated with the presence of moisture, toxic conditions and/or mold due to INSURER’s failure to perform pursuant to the Policy; be placed in situation where they have to incur the costs associating with hiring experts/professionals/counsel to force INSURER to abide by their fiduciary duty and avoid the consequential damages associated with INSURER’s failure to perform pursuant to its fiduciary duty; etc.
2.) INSURER knew that hurricane damages are of a nature that a thorough, nuanced and specialized investigation/adjustment of the claim needs to be promptly performed by qualified and prepared personnel to protect their insureds, satisfy their fiduciary duties and otherwise not engage in the Bad Faith claim handling practices at issue. That said, to the detriment of its insureds and to maximize their financial interests, INSURER disregarded the obvious and known obligations by way of the following:
(a.) Not developing, maintaining and/or instituting policies, procedures, protocol or guidelines to determine whether adjusters/personnel/vendors utilized to protect their insureds were qualified to duly assess the scope and/or value of the loss or damages.
(b.) INSURER knew that it would have to promptly hire a significant volume of licensed roofers, contractors, uniquely qualified adjusters, and/or engineers, to fully, equitably and honestly assess the scope and/or value of the loss or damages suffered by their insureds. Although INSURER will hire such experts to establish a lack of coverage as it relates to a specific claim in which they determine coverage may be in dispute, they choose to avoid such expense for self-gain when they know that a hurricane claim is undoubtedly covered under a policy.
(c.) INSURER knew that it would be in their insureds’ interests and their obligation under the insurance policy to utilize personnel/vendors to perform moisture assessments, thermal imaging, and mold assessment, throughout the insured property to honestly assess the full extent of damages and losses suffered by their insureds and ensure the insured is not living in a toxic condition. Such practice is a basic, inexpensive, efficient and industry wide accepted means of protecting their insureds, however, INSURER knows that it does not serve their financial interest since it will increase their financial obligations to insureds such as the Complainant.
(d.) INSURER knew that it would be in their insureds’ interests and their obligation under the insurance policy to carefully evaluate on a claim by claim basis whether any amounts appropriated for “depreciation” are based on sufficient facts and data, reliable principles and methods, and/or the application of reliable principles and methods. In reality, INSURER knows that it is arbitrarily, capriciously, deceptively, willfully and wantonly appropriating depreciation without any claim/item specific consideration to justify same. In the aggregate, and unbeknownst to its insureds, this sham practice allows INSURER to unjustly avoid millions of dollars in benefits owed to its insureds who are consequently placed in a position wherein they are financially coerced into choosing whether to leave their home in state of disrepair, or alternatively, searching for handyman and non-licensed vendors to perform makeshift repairs which create secondary risks and potential damages that INSURER will deny coverage for when they arise.
(e.) INSURER knew that it would be in their insureds’ interests and their obligation under the insurance policy to carefully evaluate on a claim by claim basis, and only after equitably and fully investigating/adjusting claim, the amounts owed to the insured for: overhead and profit associated with the insured’s reasonable need to utilize a general contractor; taxes associated with the repairs; permit costs associated with the repair; costs associated with various licensed trades that will be needed to effectuate the repairs; whether benefits are owed to the insured for loss of use and/or additional living expenses; personal property that may have been affected by toxic/mold/moisture conditions that developed in the home; costs associated with maintaining the continuity of the finish/appearance for pairs or sets such as cabinets, flooring, roof covering/tile/shingles, walls, ceilings, etc.
(f.) INSURER knew that it had an obligation to ensure that software programs, data bases and adjusting practices utilized to estimate the scope and value of the loss were being utilized in form that: honestly and fully delineated the line item repairs or costs that needed to be performed; pricing corresponded with licensed professionals - as opposed to handyman or non-licensed professionals; accounted for consideration of actual expenditures incurred by the insureds or otherwise compensable expenses on a repair cost basis; etc. Ultimately, INSURER knows that the adjusting practices are guided to unlawfully depriving their insureds of benefits owed under the insurance policy, which in the aggregate, serves to maximize their profits to the detriment of their insureds.
(g.) INSURER knew that it had an obligation to honestly, promptly, in continuity, reliably and fairly communicate with its insured in relation to their rights and obligations under the policy, basis for payment and/or nonpayment, policy conditions and/or exclusions which are being considered in relation to payment and/or non-payment; etc. Not only has INSURER disregarded said duty, they know that it serves their financial interest by ultimately deterring a large volume of insureds from lawfully obtaining benefits.
(h.) INSURER knew that it had an obligation to treat all insureds equally and honestly. However, and for their own financial interest, they will only start to fully consider their obligations as stated herein if the insured retains legal representation and pursues a legal action which exposes them to liabilities and costs.
(i.) INSURER knows that it has duty to duly assess whether benefits are owed to the insured in relation to the costs associated with removing, storing, cleaning, and resetting personal property in relation to repairs and/or remediation work that needs to be performed. This duty is ignored by INSURER to maximize their own financial interests. Further, they have a duty to assess whether the personal property has been contaminated by way of toxic moisture conditions that developed due to the loss and consequential damages.
(j.) Although from the onset of the Loss INSURER will have no good faith basis to deny coverage in part and/or in whole for a loss/damage, they will delay notifying the insured that coverage has been accepted, and/or otherwise delay performing, in order to: maximize their financial interests; unlawfully and deceptively withhold monies for their own use; utilize policy conditions as a shield in litigation; utilize policy conditions at later date to further delay payment when the insured demands performance under the policy; and/or so as to otherwise implement a deceptive and immoral scheme to deprive insureds of benefits owed under the policy.
(k.) INSURER’S Bad Faith conduct as described places the insured in a position that it has too unnecessarily incur expert fees to secure judicial relief by way of a legal action. Moreover, and as part of the Bad Faith practice, INSURER will await the insured’s post-suit retention of an expert to retain a designated/pre-disposed (due to financial biases) experts to further delay their obligations to their insured and the consequential liabilities that the legislature has imposed to deter INSURER from engaging in the Bad Faith practice.
To cure the above stated immoral, deceptive, unlawful and collectively defined general business practice of Bad Faith claims handling practices that are knowingly, willfully, wantonly and/or with a reckless disregard for the insured’s interests being implemented, INSURER must issue payment in the amount of $189,481.62, minus prior payments and the applicable deductible within 60 days.
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The submitter hereby states that this notice is given in order to perfect the rights of the
person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes.
Before submitting a Notice using this system, please verify that all text has been entered
correctly and completely. Once the Notice has been submitted, the text cannot be changed
or deleted.
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DFS-10-363
Rev. 10/14/2008
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