Fillable Malpractice Liability Claims Information (copy this form to

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Malpractice Liability Claims Information (copy this form to

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Country of origin: US
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Malpractice Liability Claims Information (copy this form to report multiple claims) If no claims, please mark NA.
Name of patient involved:
In which state did the action take place? Case number (if applicable)
Which court?
(If private compromise or settled before initiation of civil action, state here)
Current status of claim:
Other Dismissed (no money paid out) Open (pending) Closed (settled)
Amount of judgment or settlement $ Amount paid on your behalf $
Month and year of event precipitating claim:
Month and year of lawsuit:
Insurance carrier at time:
What is/or was your status? Primary defendant Co-defendant
Other
Please provide specifics in reference to the adverse event including the allegations and your role in the event:
Applicant Name: Date:
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Completed 2 June 2022

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