Medical 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

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

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