Ed. 05/10 Page 1 of 2
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Name of Insurance Company to which Application is made (herein called the “Insurer”)
EMPLOYED LAWYERS PROTECTION PLUS
SUPPLEMENTAL CLAIM FORM
This form is to be completed by an Applicant or Insured who has been involved in any claim or suit or is
aware of an incident which may give rise to a claim. Submit one form for each claim or incident. If space is
insufficient to answer any question completely, please attach a separate page to the application. DO NOT
ATTACH SUIT PAPERS.
1. Full name of the Applicant :
2. Full name(s) of individuals(s) or firm involved in the claim:
3. Full name of the Claimant:
4. Indicate whether: Claim / Suit Incident / Potential Claim
5. Date and location of alleged error:
6. Date of the claim:
7. Additional defendants:
8. This claim is: OPEN CLOSED
9. If CLOSED, indicate the date closed:
10. Please complete the following:
If Claim is still open:
A. Claimants settlement demand: $
B. Defendant’s offer for settlement: $
C. Insurance Company’s loss reserve: $
D. Deductible: $
E. Limit of Liability: $
F. Amounts paid to date: $
If Claim is closed:
A. Total loss paid including deductible(s): $
B. Expenses paid in excess of deductible: $
C. Deductible: $
D. Settlement reached via:
Court Judgment Formal Mediation/Arbitration Proceeding Out of Court Settlement
11. Name of Insurance Company:
12. Claim Number:
13. Description of claim, suit or incident: Please do not attach suit papers. Each question on the form must be
answered completely
.
