INSURANCE CLAIM DENIAL APPEAL

(Florida – Comprehensive Template)
[// GUIDANCE: This template is intentionally structured as a contractual-style “Appeal and Settlement Framework” so counsel may convert it into (i) a stand-alone appeal letter, (ii) a formal pre-suit agreement, or (iii) an exhibit to litigation pleadings. Delete any provisions that are unnecessary for the chosen use-case.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

Insurance Claim Denial Appeal and Settlement Framework
Effective Date: [DATE]

This Appeal (“Appeal”) is entered into by and between:

(a) [INSURED LEGAL NAME], a [STATE] [ENTITY TYPE] with its principal residence/business address at [ADDRESS] (“Insured”); and

(b) [INSURER LEGAL NAME], a [STATE OF FORMATION] insurance company authorized to transact insurance in Florida, having its principal office at [ADDRESS] (“Insurer”).

Recitals

A. Insured is the named insured under Policy No. [POLICY NUMBER] issued by Insurer (the “Policy”).
B. Insured submitted Claim No. [CLAIM NUMBER] (the “Claim”) on [SUBMISSION DATE] for loss arising on or about [DATE OF LOSS].
C. Insurer issued a written denial dated [DENIAL DATE] (the “Denial Letter”).
D. Insured timely initiates this Appeal pursuant to applicable Florida insurance law, the Policy terms, and Insurer’s internal appeal procedures.
E. The parties desire to establish binding procedures, deadlines, and remedies in connection with the Appeal, subject to the limitations set forth herein.

NOW, THEREFORE, in consideration of the mutual covenants and other valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows.

2. DEFINITIONS

For purposes of this Appeal, capitalized terms have the meanings set forth below. All references to singular include the plural and vice-versa.

“Adjuster” – The licensed individual(s) or firm appointed by Insurer to re-evaluate the Claim.

“Appeal” – The formal request by Insured for reconsideration of the Denial Letter, including all submissions, supplemental proofs, and procedures contemplated herein.

“Bad Faith” – Any action or omission by Insurer that, under applicable Florida insurance law, may constitute a failure to settle claims in good faith, or to promptly and properly investigate or pay claims when liability is reasonably clear.

“Business Day” – Any day other than Saturday, Sunday, or a state-recognized holiday in Florida.

“Claim Payment” – Any monetary amount finally determined to be due and payable to Insured under the Policy as a result of this Appeal.

“Documentation Deadline” – The date that is [NUMBER] Business Days after the Effective Date, by which Insured must supply all Supporting Documentation.

“Evaluation Period” – The period beginning on Insurer’s receipt of a complete Appeal Package and ending [NUMBER] days thereafter, during which Insurer must issue a Final Determination.

“Final Determination” – Written notice from Insurer either (i) overturning the Denial Letter in whole or part and detailing Claim Payment, or (ii) affirming the Denial Letter.

“Supporting Documentation” – All documents, photographs, expert reports, receipts, and other evidence reasonably necessary for a full and fair evaluation of the Claim.

3. OPERATIVE PROVISIONS

3.1 Timely Filing. Insured represents that this Appeal is filed within the time limits prescribed by (a) the Policy, and (b) Florida insurance regulations requiring internal appeals to be lodged no later than [APPEAL DEADLINE] days after receipt of the Denial Letter.

3.2 Submission of Supporting Documentation.
(a) Insured shall deliver a complete Appeal Package, including this executed Appeal and all Supporting Documentation, to Insurer no later than the Documentation Deadline.
(b) Delivery shall be by [E-MAIL / CERTIFIED MAIL / OVERNIGHT COURIER] with confirmation of receipt.

3.3 Insurer Re-Evaluation Obligations.
(a) Insurer shall assign the Claim to an Adjuster possessing authority to reverse, amend, or affirm the Denial Letter.
(b) During the Evaluation Period, Insurer shall:
i. Conduct a full, fair, and prompt investigation consistent with Florida claim-handling standards;
ii. Communicate in writing at least every [NUMBER] Business Days regarding the status of the Appeal; and
iii. Request additional information only if reasonably necessary and identify specific deficiencies.

3.4 Claim Payment. If Insurer determines that coverage exists in whole or in part, Insurer shall tender the undisputed portion of the Claim Payment within [NUMBER] Business Days after issuing the Final Determination, subject to the Policy Limits.

3.5 Conditions Precedent. Completion of the procedures in Sections 3.1–3.4 is a condition precedent to either party initiating litigation or arbitration concerning the Claim, except in circumstances involving imminent statute-of-limitations expiry or requests for injunctive relief under Section 8.4.

4. REPRESENTATIONS & WARRANTIES

4.1 Mutual Authority. Each party represents that it has full power and authority to enter into and perform this Appeal.

4.2 Insured Representations. Insured represents and warrants that:
(a) All Supporting Documentation is accurate and complete to the best of Insured’s knowledge;
(b) No material information relating to the Claim has been intentionally withheld; and
(c) Insured will cooperate reasonably and in good faith with Insurer’s investigation.

4.3 Insurer Representations. Insurer represents and warrants that:
(a) The Adjuster will be impartial and will act in compliance with Florida’s claim-handling regulations;
(b) Insurer will not unreasonably delay or deny Claim Payment; and
(c) Insurer’s communications with Insured will be timely, clear, and documented.

4.4 Survival. The representations and warranties in this Section survive the Final Determination for [NUMBER] years or the applicable statute of limitations, whichever is shorter.

5. COVENANTS & RESTRICTIONS

5.1 Affirmative Covenants of Insured. Insured shall:
(a) Make property/records available for inspection upon reasonable notice;
(b) Execute any necessary proofs of loss; and
(c) Provide sworn statements or examinations under oath if required by the Policy.

5.2 Affirmative Covenants of Insurer. Insurer shall:
(a) Maintain complete claim files and document its evaluation;
(b) Preserve all communications and internal notes relevant to the Claim for not less than [NUMBER] years; and
(c) Promptly correct any errors discovered during the Appeal process.

5.3 Negative Covenants. Neither party shall impede or frustrate the Appeal procedures or undertake actions intended solely to delay resolution.

6. DEFAULT & REMEDIES

6.1 Events of Default. Each of the following constitutes an “Event of Default”:
(a) Failure by Insurer to issue a Final Determination within the Evaluation Period;
(b) Failure by Insurer to pay any undisputed Claim Payment when due;
(c) Insured’s willful submission of materially false information; or
(d) Either party’s breach of a material covenant that remains uncured for [NUMBER] Business Days after written notice.

6.2 Cure Period. The non-defaulting party shall provide written notice specifying the Event of Default and allow the defaulting party the applicable cure period.

6.3 Remedies.
(a) Upon Insurer Default, Insured may:
i. Initiate litigation under Section 8.2 or arbitration under Section 8.3;
ii. Seek statutory interest, attorney’s fees, and consequential damages; and
iii. Assert a Bad Faith claim under Florida law after exhaustion of pre-suit notice requirements.
(b) Upon Insured Default, Insurer may suspend its obligations until cured or seek any available contractual or equitable relief.

6.4 Attorney’s Fees. The prevailing party in any action arising from or relating to this Appeal is entitled to recover reasonable attorney’s fees and costs, consistent with Florida law.

7. RISK ALLOCATION

7.1 Indemnification. Not applicable as agreed in metadata. Each party retains all defenses and rights under the Policy and Florida law.

7.2 Limitation of Liability. Insurer’s aggregate liability under this Appeal shall not exceed the applicable Policy Limits, exclusive of any statutory interest or attorney’s fees recoverable under Florida law.

7.3 Force Majeure. Neither party is liable for failure or delay in performing obligations due to events beyond its reasonable control, provided the affected party gives prompt written notice and resumes performance as soon as practicable.

8. DISPUTE RESOLUTION

8.1 Governing Law. This Appeal and any disputes hereunder are governed by Florida insurance law, without regard to conflict-of-laws principles.

8.2 Forum Selection. Subject to Section 8.3, the parties consent to exclusive jurisdiction and venue in the state courts of [COUNTY], Florida.

8.3 Optional Arbitration. Either party may elect binding arbitration administered by [AAA / JAMS] in accordance with its Commercial Arbitration Rules. Election must be made by written notice within [NUMBER] days after an Event of Default.
[// GUIDANCE: Delete if arbitration is not desired.]

8.4 Injunctive Relief. Notwithstanding any other provision, a party may seek injunctive or equitable relief (including an order compelling Claim Payment) in a court of competent jurisdiction to prevent irreparable harm.

8.5 Jury Trial. Each party acknowledges the constitutional right to a jury trial and agrees that any waiver of that right must be set forth in a separate, conspicuous paragraph and be knowingly and voluntarily executed.
[// GUIDANCE: Insert a conspicuous, boldfaced jury-waiver clause here if both parties desire to waive jury trial.]

9. GENERAL PROVISIONS

9.1 Amendments. This Appeal may be amended only by a written instrument executed by both parties.

9.2 Waiver. No waiver of any provision or breach is deemed a waiver of any other provision or breach.

9.3 Assignment. Neither party may assign its rights or delegate its obligations without prior written consent, except that Insurer may assign to an affiliate authorized to transact insurance in Florida.

9.4 Successors & Assigns. This Appeal is binding upon and inures to the benefit of the parties and their respective successors and permitted assigns.

9.5 Severability. If any provision is held invalid or unenforceable, the remaining provisions remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to render it enforceable while preserving its intent.

9.6 Integration. This Appeal, together with the Policy and any schedules or exhibits, constitutes the entire agreement regarding the subject matter and supersedes all prior or contemporaneous communications.

9.7 Counterparts; Electronic Signatures. This Appeal may be executed in counterparts, each of which is deemed an original, and all of which constitute one instrument. Signatures transmitted electronically or by facsimile are deemed original.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the parties have executed this Appeal as of the Effective Date.

[INSURED LEGAL NAME]
By: ____
Name: ____
Title (if entity): ___
Date: _________

STATE OF [STATE]
COUNTY OF [COUNTY]

Subscribed and sworn before me on _/_/______ by [NAME].

Notary Public

[INSURER LEGAL NAME]
By: ____
Name: _____
Title: _____
Date: ______

STATE OF [STATE]
COUNTY OF [COUNTY]

Subscribed and sworn before me on _/_/______ by [NAME].

Notary Public

[// GUIDANCE:
1. Attach schedules for Supporting Documentation or claim worksheets if desired.
2. Confirm all bracketed placeholders are completed before execution.
3. Tailor timeframes to comply with current Florida regulatory deadlines.
4. Consider sending a separate Civil Remedy Notice if pursuing Bad Faith after exhausting this Appeal.
]