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COVERYS SPECIALTY INSURANCE COMPANY (Risk Placement Services, Inc.)

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  • 22 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

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COVERYS SPECIALTY INSURANCE COMPANY
INSTRUCTIONS: Complete a SEPARATE Supplemental Claim Form for each actual/potential claim. Answer EACH question fully.
Attach a supplement when necessary to expand upon information in any one area below.
1) Applicant’s Name:
2) Full name of individual(s) or applicant who was/were involved/named in the claim:
3) Additional Defendants/Others Involved:
4) Full name of Claimant:
5) (a) Date of alleged error: (b) Date claim was made:
6) To what insurance company did you report this claim?
7) Present status of claim (check one): Open/Incident In Suit ClosedUnknown
8) If Closed:
Total damages paid and outstanding (including deductible):
Total defense costs paid if known: Date closed:
9) If Open/Pending:
a) Claimant’s settlement demand: $ b) Insurer’s Reserve: $
c) Defendant’s offer for settlement: $ d) Amount paid to date: $
e) Amounts Unknown 
10) Claim Classifications: (Please check () all that apply):
Negligent Treatment & Procedures Wrongful Death Falls with Injury
Blood Draw Injury Burns Infection Injury
Delayed Treatment & or diagnosis Needle Sticks Reposition / transfer
Negligent Hiring/credentialing/training Abuse / Neglect Communication Error
Failure to Monitor Assault / Battery Fraud / Misrepresentation
Breach of Fiduciary Duty Negligent Supervision
11) Description of claim or incident. Please do not attach copies of papers, or instruct us to refer to file or contact Company
representative. Details must be provided to allow an evaluation of the claim or incident. Provide case and events details
(please attach supplement if necessary):
12) What steps have been taken to prevent a similar claim?
Applicant understands the information submitted herein becomes a part of the Insurance Application and is subject to the
same representations and conditions. This form must be signed and dated by the applicant for whom the coverage is requested.
Applicant’s Signature: Date:
Name of Agent/Producer: License #:
Signature of Agent/ Producer: Date:
(2/18) Page 1 of 1
CHIROPRACTOR PROFESSIONAL LIABILITY SUPPLEMENTAL CLAIM FORM
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COVERYS SPECIALTY INSURANCE COMPANY (Risk Placement Services, Inc.)

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Completed 30 July 2020

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