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FLEXI PLUS FIVE SUPPLEMENTAL CLAIM FORM Name of (Philadelphia Insurance Companies)

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Page 1 of 3
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
FLEXI PLUS FIVE
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: _______________________________________________________________
Ed. 05/10
Print Application
Clear Application
Page 2 of 3
13. Description of claim, suit 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 ha
s your firm taken to prevent a recurrence of such a claim in the future?
____________________________________________________________________________________
____
_________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
I understand that the information sub
mitted herein becomes a part of my Philadelphia Insurance
Companies Flexi Protection Plus 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 EXECUTIVE DIRECTOR)
__________________________________________ _____________________________________________
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 Producer/Broker)
Producer Agency
Agency Taxpayer ID or SS No. Producer License Number
Address (Street, City, State, Zip)
Ed. 05/10
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Clear Application
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
Ed. 05/10
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FLEXI PLUS FIVE SUPPLEMENTAL CLAIM FORM Name of (Philadelphia Insurance Companies)

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Completed 7 November 2020

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