Chiropractor Professional Liability Supp Claim
PI-CPHC-CLAIM ME 06/12 Page 1 of 3
Malpractice Insurance
Chiropractic Professional Liability Application
SUPPLEMENTAL CLAIM INFORMATION
Submit one form for each claim or incident. If space is insufficient to answer any question completely,
please use the Additional Information page attached to this application.
1. Full name of the Applicant:
2. Full name of the Entity which reported the claim (if different from above):
3. Full name of the claimant:
4. Indicate whether: Claim / Suit Incident / Potential Claim
5. Date / Period of alleged error:
6. Date the claim was reported to the insurance carrier:
7. Other parties against which this claim is made:
8. This claim is: Open Closed
9. If CLOSED, indicate the date closed:
10. Please complete the following:
If claim is still open:
a. Claimant’s settlement demand: $
b. Defendant’s offer for settlement: $
c. Insurance company’s loss reserve: $
d. Deductible: $
e. Total loss and expenses paid to date: $
If claim is closed:
a. Loss paid in excess of deductible: $
b. Expenses paid in excess of deductible: $
c. Deductible: $
d. Settlement reached via:
Court Judgment Formal mediation/Arbitration proceeding Out of court settlement
Note: If information is not available, please provide a copy of the suit papers.
11. Name of Insurance company:
12. Claim number:
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Chiropractor Professional Liability Supp Claim
PI-CPHC-CLAIM ME 06/12 Page 2 of 3
13. Description of claim / incident:
a. Provide a full description of the claim/incident. Please include the events that
lead up to the claim, nature of the alleged injuries sustained against you or your
Corporation, limited liability company or limited liability partnership and any
allegations made against you in which you worsened the condition.
b. Is this claimant a patient you have treated in the past?
If no, fully explain claimant’s relationship
Yes No
c. Is there documentation within the patient’s file of their medical history and your
treatment plan?
d. What actions have you 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 Cover-Pro
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Healthcare application and is subject to the same conditions as stated on that
application.
NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES
INCLUDE IMPRISONMENT, FINES OR DENIAL OF INSURANCE BENEFITS.
Name (Please Print/Type) Title
(
MUST BE SIGNED BY A PRINCIPAL PARTNER OR OFFICER)
_______________________________________
Signature Date
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
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Chiropractor Professional Liability Supp Claim
PI-CPHC-CLAIM ME 06/12 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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