Medical Claim Form

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Contact Information
Preferred contact information for all future correspondence regarding this claim.

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

Patient Information
Claim Information

Lawsuit Filed? *

 

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

Claims Advice or Report a Claim

From advice about a sensitive patient encounter or situation to responding to a written demand from an attorney, we’re here to support you.

Report a Medical Malpractice Claim

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