PI-PLSP-CLAIM 03/10 Page 1 of 3
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
COVER-PRO
SM
APPLICATION
SUPPLEMENTAL CLAIM INFORMATION
Submit one form for each claim or incident. If space is insufficient to answer any question completely,
please use the Additional
Information page attached to this application.
1. Full name of the Applicant Firm:
2. Full name of the firm which reported the claim
(if different from a
bove):
3. Full name
of the claima
nt:
4. Indicate whether: Claim / Suit Incident / Potential claim
5. Date / Period of alleged error:
6. Date the claim was reported to the insurance carrier:
7. Other parties against which this claim is made:
8. This claim is: OPEN CLOSED
9. If CLOSED, indicate the date closed:
10. Please complete the following:
If claim is still open:
A. Claimant’s settlement demand: $
B. Defendant’s offer for settlement: $
C. Insurance company’s loss reserve: $
D. Deductible: $
E. Total loss and expenses paid to date: $
If claim is closed:
A. Loss paid in excess of deductible: $
B. Expenses paid in excess of deductible: $
C. Deductible: $
D. Settlement reached via:
Court judgment Formal mediation / Arbitration proceeding Out of court settlement
Note: If information is not available, please provide a copy of the suit papers.
11. Name of Insu
rance company:
12. Claim number:
