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CLAIMS INFORMATION SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0005 07 13 Page 1 of 2
CLAIMS INFORMATION SUPPLEMENTAL APPLICATION
APPLICANT’S INSTRUCTIONS:
This form is to be completed
if the Applicant showed any activity in the CLAIMS ACTIVITY Section VI. on the main
application. If space is insufficient to answer any question fully, attach a separate sheet. Answer all questions completely.
APPLICANT
1. a. Name of Attorney involved in the claim: ____________________________________________
b.
Name of the Firm involved in the claim:
____________________________________________
2.
Additional Defendants:
____________________________________________
3.
Full name of Claimant / Plaintiff:
____________________________________________
4. Present Status of Claim (Check One):
In Suit Formal Claim
Open Incident / Potential Claim Closed
5.
a.
Date of alleged error:
____________________________________________
b.
Date claim / incident made against the Applicant:
____________________________________________
c. Date claim / incident reported to Insurer: ____________________________________________
d.
Name of insurer to whom you reported claim:
____________________________________________
6.
If claim is closed, answer a., b., and c. below. If claim is open, please go to question 8.
a.
Total defense costs paid:
$ __________________
Total indemnity paid: $ __________________
b.
Was loss paid by insurer?
Yes No If yes, total deductible applied: $
Total paid, excess of deductible:
$ __________________
c. Out of Court Settlement: Yes No Date of settlement: _________
Court Judgment:
Yes No Date of judgment: __________
7.
If claim is open, please answer the following:
a.
Claimant’s settlement demand:
$ ______________
b.
Defendant’s offer for settlement:
$ ______________
c. Insurer’s loss reserve: $ ______________
d.
Applicant / Insured’s estimate of settlement amount:
$ ______________
8. Description of claim or incident which may give rise to claim (use additional paper as needed):
a. Alleged act, error, or omissions upon which claim or incident is based: __________________________
b.
Description of events leading to claim or incident: ___________________________________________
c.
Current status: ______________________________________________________________________
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the
third degree.
Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
MALP 0005 07 13 Page 2 of 2
crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And West Virginia Applicants: Any person who
knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Notice to Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means an act committed by any
person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief
that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of,
or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial
insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, any information concerning any fact material thereto.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Notice to Maine, Tennessee, Virginia and Washington Applicants: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines, or denial of insurance benefits.
Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other states: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime and subjects the person to criminal and civil penalties.
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Completed 23 November 2020

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