Name of Insurer:

FEIN:

Claim ID:

Coverage Code:

Date of

Injury:

Date Reported to Insurer:  

Date Claim

Opened:

Date Claim

Reopened:

Date of Original

Closure:

Profession or Business Code:

Date of Birth:

Type of Practice Code:

Specialty:

Insured's Name:

Board Certified:

License Number or FEIN:

County:

Place Where Injury Occurred Code:

Location in Institution Code:

Name of Institution:

County:

Injured Person's Name:

Social Security Number:

Gender:

Age Category:

County:

Total Insured Defendants Involved in Claim:

Companion Claim File ID#:

Person Responsible for Preparing Report:

Title:

Contact Person

Telephone Number:

Email Address:

Plaintiff Attorney's Name or Law Firm:

City:

State:

Nature and Substance of Claim:

Act or Omission Codes:

Severity of Injury Code:

Date of  Closure:

Claim Disposition Code:

Settlement Code:

Review Panel Code:

Binding Arbitration Code:

Court Information − Court Code:

Appealed (Y/N):

County:

Result of Appeal:

Docket Number:

Other Post Trial Motions:

Amount Awarded by Circuit Court:

Economic Damages:

Date of award:

Non-economic Damages:

Indemnity Paid/Payable by You under This Policy on Behalf of This Insured/Defendant:

Economic Damages:

Non-economic Damages:

Loss Adjustment Expense Paid/Payable by You under This Policy to Defense Counsel:

All other Allocated Loss Adjustment Expenses Paid/Payable by You under This Policy:

Indemnity Paid/Payable by You under All Policies on Behalf of This Insured/Defendant:

Other Indemnity Paid by You or on Behalf of This Defendant:

D)   Deductible Paid by Insured:

E)    Indemnity Paid under Excess Limits Policy by Another Insurer:

F)    Amount Paid under Self-insured Retention:

G)    Amount Paid above Stop Loss Limit:

Claimed Medical Expense:

Claimed Wage Loss:

a)

Court Docket Number:

b)

Named Defendant:

c)

Named Plaintiff:

d)

Award Date:  MM/DD/YYYY

e)

County:

f)

Amount Awarded by Circuit Court:  $

g)

Economic Damages Awarded:  $

h)

Non-economic Damages Awarded:  $

i)

Court Verdict:

j)

Disposition of Post-Trial Motions:

k)

Name of Contact Person at the Clerk of Circuit:

l)

Telephone Number of Contact Person:

m)

Email Address of Contact Person: