Medical Claim Form

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Insured Information

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

Claim Information

Lawsuit Filed? *

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

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


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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