Claim Form

All fields marked with * are required.

Insured Information

Insured Name *

Policy Number *

Preferred method of contact *

Office Phone *

Mobile Phone *

Email Address *

Your email address will never be sold. It will be used to send you important notices.

Name of person completing form *

Relationship to insured *

Claim Information

Type of claim *

Lawsuit Filed? *

Yes No

Date Received *

Patient Name *

Location of alleged event *

Nature of Alleged Injury (if known) *

Date of alleged injury (mm/dd/yyyy) *

First date of treatment (mm/dd/yyyy) *

Last date of treatment (mm/dd/yyyy) *

Additional comments

*Comments are for basic reporting details only. A claims representative will contact you for further details.

Attachment:

NOTE: Please do not attach any patient records to this form.

Invalid

I acknowledge that I have read my state's claims fraud warning. *

Coverage is subject to all terms, conditions and exclusions of the policy issued and any applicable endorsements.