Fillable Medical Negligence Insurance Claims Reporting (Department of Technology and Information)

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Medical Negligence Insurance Claims Reporting (Department of Technology and Information)

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BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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REPORT OF DELAWARE MEDICAL NEGLIGENCE CLAIMS 18 Del. C. § 6820
(PLEASE TYPE OR PRINT CLEARLY)
TO:
State of Delaware Department of Insurance
ATTN: Consumer Services – Medical Malpractice
1351 West North Street, Suite 101
Dover, DE 19904
(302) 674-6227
medmal@delaware.gov
FROM: Insurer’s Name:
Insurer’s NAIC No.:
Insurer’s Address:
Insurer’s Telephone No.:
1. INSURED PERSON OR ENTITY
Name:
Professional
affiliation, if any:
Business Address:
Business Telephone:
Field or Specialty:
Delaware License No.:
2. CLAIMANT
Name(s):
Claim
No.:
3. CIVIL SETTLEMENT WITHOUT LAWSUIT
If this claim was settled without a lawsuit being filed, please provide the following information:
A. Was payment made to the claimant: Yes No
B. Date of settlement
C. Date claim closed
D. Amount of insurer’s payment to Claimant excluding attorneys fees $
E. Amount of insurer’s legal fees and non-medical costs related to the claim $
F. If more than one person or entity contributed to the settlement:
•
The full amount of settlement $
•
The full amount of legal fees and non-medical costs related to the claim
irrespective of whether the claimant received any payment $
•
Names of other parties to the settlement
4. SETTLEMENT OR JUDGMENT RESULTING FROM LAWSUIT
If this claim was settled or adjudicated after the filing of a lawsuit, please provide the following
information:
A. Court name (including state/county in which filed)
B. Name(s) of Plaintiff(s) other than Claimant
C. Name(s) of Defendant(s) other than insured
D. Docket Number
E.
Disposition
Settlement
Verdict
in favor of: Claimant
F. Date of disposition
Insured Other
G. If the disposition was in favor of the Claimant:
Total amount of settlement/verdict excluding insured’s legal fees and related non-medical
costs $
Total
amount of insured’s legal fees and related non-medical costs irrespective of
whether the Plaintiff received any payment
$
H. Total amount paid by and/or attributable to insured for settlement/verdict, legal fees and
non-medical costs irrespective of whether the Plaintiff received any payment
$
5. DESCRIPTION OF THE CLAIM
Please provide a detailed description of the claim in general and the specific allegations against
the insured.
6. NOTICE TO THE INSURED
Has the insured been provided with a copy of this form: Yes No
Date
this notice was provided to insured:
Except as otherwise required by law, information reported on this form to the Commissioner shall be kept
confidential, shall not be subject to disclosure to the public pursuant to the Freedom of Information Act (29 Del. C.
Chapter 100) or for any other reason, and shall not be subject to subpoena or any other legal process.
Rev 7/19/05 Approved by the Board of Medical Practice 7/19/05
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Medical Negligence Insurance Claims Reporting (Department of Technology and Information)

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Completed 13 August 2020

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