Name of Applicant
Mailing Address
Contact Person
Phone #
Fax #
E-mail Address
(For more than four (4) claims, please photocopy this page, complete and attach)
Please complete, in chronological order, for any closed, pending or potential claim.
1.
Claimant's/Plaintiff's Name
Date care rendered
Date claim reported
Status:
Open
Closed
Date closed
If closed, was any indemnity payment or award made?
Yes
No
If yes, what amount?
If open, what is the amount of loss reserve or damages sought?
Name of Insurance Company Defending You
Description of claim (include type of treatment, result of treatment, your involvement)
2.
Claimant's/Plaintiff's Name
Date care rendered
Date claim reported
Status:
Open
Closed
Date closed
If closed, was any indemnity payment or award made?
Yes
No
If yes, what amount?
If open, what is the amount of loss reserve or damages sought?
Name of Insurance Company Defending You
Description of claim (include type of treatment, result of treatment, your involvement)
3.
Claimant's/Plaintiff's Name
Date care rendered
Date claim reported
Status:
Open
Closed
Date closed
If closed, was any indemnity payment or award made?
Yes
No
If yes, what amount?
If open, what is the amount of loss reserve or damages sought?
Name of Insurance Company Defending You
Description of claim (include type of treatment, result of treatment, your involvement)
4.
Claimant's/Plaintiff's Name
Date care rendered
Date claim reported
Status:
Open
Closed
Date closed
If closed, was any indemnity payment or award made?
Yes
No
If yes, what amount?
If open, what is the amount of loss reserve or damages sought?
Name of Insurance Company Defending You
Description of claim (include type of treatment, result of treatment, your involvement)