Client Name: Client Number:
INSTRUCTIONS: This form is to be completed if the applicant is currently, or ever has been involved in any claim or suit, or is aware of
circumstances that may reasonably be expected to give rise to a claim or suit. Complete a separate form for each claim, suit or
circumstance. If space is insufficient to fully answer each question, please use a separate sheet. Please do not leave any question blank.
Please Note: This Supplement is for underwriting information only and does NOT constitute notice of claim to the Company. If you wish
to provide the Company with notice of claim, check the Claims provisions of your policy and/or seek guidance from your broker.
This is a(n) Claim Suit Incident
Status of claim/suit/incident: Open Closed ___________ (Date of Closure)
Date of Claim or Suit (if applicable): ______________ Date Reported to Company (if applicable):___________________
Provide the details below. In addition, provide a carrier loss run, if available
Claimant’s Settlement Demand: $ __________ Total Paid: $___________
Defendant’s Offer for Settlement: $__________ Indemnity Paid: $___________
Insurer’s Indemnity Reserve: $__________ Expenses Paid: $___________
Expenses Paid to Date: $__________
Expense Reserve: $__________
List the defendants named or likely to be named in the claim or suit:______________________________________________________
Full name(s) of Claimant(s): _____________________________________________________________________________________
Name(s) of Insurer(s) responding to this claim or incident (if applicable):___________________________________________________
Description of alleged act, error or omission upon which claim is or may be based:__________________________________________
Description of the type and extent of injury or damage which is or may be alleged to have been sustained:
Provide any corrective actions you have taken to prevent similar actions in the future. ________________________________________
As a supplement to the application, the undersigned, recognizes that he/she has a continuing obligation to declare to the best of his/her knowledge and
belief that the statements contained herein are true and are the basis of the acceptance of the risk or the hazard assumed by the Insurer under this
Policy. It is further agreed by the undersigned, that if the Insurer issues the coverage for services which the applicant is requesting in the Policy, it is in
reliance upon the truth of such representations. It is agreed that, although the signing of this Supplement to the Application does not commit the
undersigned to purchase such additional insurance, the statements made herein shall be included with those made in the Application and become the
basis of the Policy should one be purchased. The Insurer is hereby authorized to make any investigation and inquiry in connection with the Application
and all supplements thereto, as it deems necessary.
Signature_________________________________ Title_________________ Date_________________
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