Fill - Free fillable EMPLOYMENT PRACTICES LIABILITY SUPPLEMENTAL CLAIM FORM Name of (Philadelphia Insurance Companies) PDF form

Ed. 05/10) Page 1 of 3

__________________________________________________________________________

Name of Insurance Company to which Application is made (herein called the “Insurer”)

EMPLOYMENT PRACTICES LIABILITY

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 Firm: ________________________________________________________________

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:_____________________________________________________________________________

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Ed. 05/10) Page 2 of 3

13. Description of claim, sui

t or incident: Please do not attach suit papers. Each question on the form must be

answered completely.

___________________________________________________________________________________________

14. Provide a full description of alleged act, error or omission upon which the claim is based:

___________________________________________________________________________________________

15. Provide a full description of the type and extent of injury or damage allegedly sustained:

___________________________________________________________________________________________

16. What action has your firm taken to prevent a recurrence of such a claim in the future?

___________________________________________________________________________________________

I understand that the information submitted herein becomes a part of my Philadelphia Insurance

Companies Employment Practices Liability Application and is subject to the same conditions as stated

on the application.

__________________________________________ _____________________________________________

Name (Please Print) Title (

MUST BE SIGNED BY THE PRESIDENT,

CHAIRMAN OR CHIEF EXECUTIVE OFFICER)

____

______________________________________ _____________________________________________

Signature Date

The above signed warrants that he/she is authorized and has the power to complete and execute this Application,

including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other

insured persons.

Produced By: (Section to be completed by Agent/Broker)

Agent: _______________________________________Agency: ________________________________________

Agency Taxpayer ID or SS No.: ____________________________ Agent License No: ______________________

Address (Street, City, State, Zip) :

___________________________________________________________________________________________

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Ed. 05/10) Page 3 of 3

ADDITIONAL INFORMATION

This page may be used to provide additional information to any question on this

application. Please identify the question number to which you are referring.

__________________________________________ _____________________________________________

Signature Date

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EMPLOYMENT PRACTICES LIABILITY SUPPLEMENTAL CLAIM FORM Name of (Philadelphia Insurance Companies)

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