Step 3-C: DNO Specific Claim Forms

Who is Required to File a DNO Form?

The Department of Insurance requires the Directors & Officers Liability (DNO) Form to be submitted by insurers providing coverage for officers and directors liability for any claim resulting from error, omission, or negligence in the performance of the insured officers or directors services.

How to Submit a DNO Form

Now that you've completed the initial steps of creating your new closed claim form, and you understand the claim summary page you're ready to get into the details of your DNO form.

On the DNO Claim Summary page below, you'll notice that the DNO form has four primary sections:

Insured Information
Injured Information
Legal Information
Financial Information

The status of each of these four sections must be complete in order to submit the form to the Office of Insurance Regulation for review.

Note: Completing all sections of the DNO form may take some time. Feel free to save your data in the current section of the form and return to other sections as your time permits.

The DNO Claim Summary Page

Section 1: Insured Information

The first section of the DNO form provides fields in which you will enter information about the insured person or entity. The Insured Information page is displayed below.

The Insured Information Page

To Edit the Insured Information Page:

Fill in the following list of fields (Fields in blue apply only if Type: Individual is selected):

Type	Type indicates whether the insured is an individual or entity. Select Individual or Entity from the drop down box as appropriate.
First Name	The given name of the insured if the Type is Individual.
Middle Initial	The middle initial of the insured if the Type is Individual.
Last Name	The family name/surname of the insured if the Type is Individual.
Entity Name	The name of the insured company if the Type is Entity.
Street Address of Business Practice	The street address of the insured's business.
City	The city in which the insured's business is located.
State	The state in which the insured's business is located.
County	The county in which the insured's business is located.
Zip Code	The ZIP/Postal Code address in which the insured's business is located.
Policy Number	The insured's insurance policy number.
Per Claim Policy Limits	The per claim policy limits on the insured's policy.
Aggregate Policy Limits	The aggregate policy limits on the insured's policy.
Position Held by Insured	The job title of the director or officer.
Type of Corporation	The type of business in which the company is involved (e.g., civic, educational, labor).
Other Type of Corporation	If an appropriate type of business is not available in the Type of Corporation list, select "Other" from the list and type an appropriate description in this field.

Click the Save button to save your changes and return to the DNO Claim Summary Page.

Clicking the Reset button will reset all fields to blank.
Clicking the Cancel button will return you to the DNO Claim Summary page without saving your changes.

Upon clicking the Save button all address fields are verified using CODE1 validation. If the CODE1 validation does not find the address you input into the address fields, the following Address Validation page will display.

The CODE1 Address Validation Page

The CODE1 validation page will display the address data you supplied, CODE1 data that offers a possible known address that is correct, and remarks regarding the address data.

You may choose to either:

Select "User Data". Selecting this option will use the address information you supplied, rather than the CODE1 suggested address.
Select "CODE1 Data". Selecting this option will use the CODE1 address data found by CODE1 and replace the address information you supplied.
Select "Reject Report". This will ignore the CODE1 validation report entirely.

Click the Done button after making your selection to return to the Insured Information page.

Section 2: Injured Information

The next section of the DNO form allows you to add additional attorneys involved in this particular claim that are not covered by the policy. The Attorney Information page is displayed below.

The Injured Information Page

To Edit the Injured Information Page:

Fill in the following list of fields (Fields in blue apply only if Type: Individual is selected):

Type	Type indicates whether the insured is an individual or entity. Select Individual or Entity from the drop down box as appropriate.
First Name	The given name of the injured individual.
Middle Initial	The middle initial of the injured individual.
Last Name	The family name/surname of the injured individual.
Entity Name	The name of the insured company if the Type is Entity.
Date of Birth	The date of birth of the injured individual. Either type in the date of the injured individual's birth or select the date of birth from the calendar to the right of the field.
Age	This is a system calculated field. The age of the injured individual is determined based on the individual's birth date and the date of the individual's injury. This is not the individual's current age, but his/her age at the time of the injury.
Gender	The sex of the injured individual.
Injuries Claimed	This field allows you to select from multiple possible injuries sustained by the injured individual or entity.
Description of Other Injuries Claimed	If the individual sustained injuries not listed in the Injuries Claimed field, select "Other" from the Injuries Claimed field and enter a description of the injury here.
Date of Occurrence	The date on which the injury occurred.
Date Reported to Insurer	The date on which the injury was reported to the insurer.
Summary of Occurrence	A text field to enter a summary describing how the injury was sustained.

Click the Save button to save your changes and return to the DNO Claim Summary Page.

Clicking the Reset button will reset all fields to blank.
Clicking the Cancel button will return you to the DNO Claim Summary page without saving your changes.

Section 4: Legal Information

Next is the Legal Information section of the DNO form. In this form you'll fill out information pertaining to the legal action taken on the liability claim. The Legal Information page is displayed below.

The Legal Information Page

To Edit the Legal Information Page:

Fill in the following list of fields:

Date of Suit	The date the lawsuit of the injured individual was filed against the insured attorney.
Circuit Court Case Number	The circuit court case number assigned to the lawsuit.
County Suit Filed In	The county in which the lawsuit was officially filed.
Date of Final Disposition	The date of the final outcome of the lawsuit (i.e., date of the settlement or court verdict, etc.).
Stage of Legal System at Which Settlement was Reached	At what point in the legal process was the lawsuit resolved (i.e., after arbitration, after court verdict, etc.).
Date of Final Payment	Enter the date on which the malpractice claim was paid by the insurer, if a verdict rendered payment necessary. If no payment was made, leave this field blank.
Court Decision	The final decision of the court on the lawsuit, if the lawsuit was not resolved out of court. If the lawsuit was resolved out of court, select "No Court Proceedings".
Name of Other Court	If the court decision you're looking for does not appear in the Court Decision list, select "Other" from the list and enter another court decision description here.
List of Other Defendants	This is an area where you may add other defendants involved in the case that are not covered under this policy. If there are no other defendants, be sure click the checkbox next to the text "No Other Defendants Involved in this Claim". See step 3 below for more information.

Click the Save button to save your changes and return to the DNO Claim Summary Page.

Clicking the Reset button will reset all fields to blank.
Clicking the Cancel button will return you to the DNO Claim Summary page without saving your changes.

If you need to add additional defendants involved in the case that are not covered under this policy or update the list of defendants, click the Add/Update/Remove Defendant button. The Other Defendant Information page will display. If you do not need to add or update additional defendants, proceed to step 6.

The Other Defendant Information Page

To Add a Defendant:

Select Individual or Entity from the Type drop down list.
Enter the name of the entity or individual
Enter the license number of the entity or individual.
Click the Add button. You will notice the name of the entity or individual you added will appear in the Defendants Involved in this Claim box.

To Remove a Defendant:

Select the individual or entity from the Defendants Involved in this Claim box.
Click the Remove button. The defendant will be deleted.

To Update a Defendant:

Select the individual or entity from the Defendants Involved in this Claim box.
Alter the name of the individual or entity as appropriate.
Alter the license number of the entity or individual as appropriate.
Click the Update button to finalize the change.

When you are finished updating defendant information, click the Done button. This will return you to the Legal Information page.
Click the Save button to save your changes and return to the DNO Claim Summary Page.

Clicking the Reset button will reset all fields to blank.
Clicking the Cancel button will return you to the DNO Claim Summary page without saving your changes.

Section 5: Financial Information

The last section of the DNO form you'll need to fill out is the Financial Information section. This section captures the monetary values paid to the plaintiff, if any, as well as costs incurred by the defendant. The Financial Information page is displayed below.

The Financial Information Page

To Edit the Financial Information Page:

Fill in the following list of fields:

Plaintiff Payment Indicator	Click the radio button next to Yes or No to indicate whether there was a settlement or judgment resulting in payment to the plaintiff.
Indemnity Paid by Insurer	If the plaintiff received payment as a result of the settlement or judgment, list the amount of the indemnity paid by the insurer on behalf of the insured individual.
Deductible Paid by Defendant	List the amount of the deductible paid by the defendant.
Defense Counsel Expense	List the amount of loss adjustment expense paid to the defense counsel.
Other Expenses	List all other loss adjustment expenses paid.
Non-Economic Loss	If the plaintiff received payment as a result of the settlement or judgment, list the amount paid for the injured person's non-economic loss.
Economic Loss Expenses	If the plaintiff received payment as a result of the settlement or judgment, list the amount paid for the injured person's economic loss.
Punitive Damages	If the plaintiff received payment as a result of the settlement or judgment, list the amount paid for the punitive damages.
Safety Management	List any safety management steps that were taken as a result of this incident of medical malpractice, if any were necessary.

Click the Save button to save your changes and return to the DNO Claim Summary Page.

Clicking the Reset button will reset all fields to blank.
Clicking the Cancel button will return you to the DNO Claim Summary page without saving your changes.