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Claim Number :
Department File Number :
 
Licensed Insurer Name :
Licensed Insurer FEIN :
Licensed Insurer NAIC Company Code :
 
Self Insurer First Name :
Self Insurer Last Name :
Self Insurer Entity Name :
Self Insurer Prof. License Number :
 
Insured Policy Number :
Insured (Doctor's/Physician's) First Name :
Insured (Doctor's/Physician's) Last Name :
Insured Entity Name :
Insured (Doctor's/Physician's) License Number :
 
Date Injury Occurred : To
Date Injury Reported : To
County Injury Occurred In :
Severity of Injury :
 
Court Case Number :
Final Disposition :
Date of Final Disposition : To
Court Decision :
County Suit Filed In :
Arbitration :
Date Suit Filed : To
Stage Settlement Reached :
 
Indemnity Paid :Range ($): 
Defense Expense Paid :Range ($): 
Non Economic Paid :Range ($): 
 
Date Submitted : To
Date Updated : To