Fillable Supplemental Claim Form for Professional Liability Insurance (Risk Placement Services, Inc.)

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Supplemental Claim Form for Professional Liability Insurance (Risk Placement Services, Inc.)

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The Supplemental Claim Form for Professional Liability Insurance (Risk Placement Services, Inc.) form is 1 page long and contains:

  • 1 signature
  • 0 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

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QBE and the links logo are registered service marks of QBE Insurance Group Limited
QBPC 30 07 09 15 Page 1 of 1
Instructions
Provide details below for each claim, fact, circumstance or situation. If more space is needed, attach additional pages.
Applicant information
Full name of applicant
First claim information
1. Date claim made
Date of alleged error
Current status/Date settled
Claim, suit or incident
Claimant(s)/Plaintiff(s)
Additional defendant(s) (if any)
Nature of claim and allegations
Name of insurance company
Date reported to insurance company
Loss
Expense
Amount reserved
$
$
Amount paid
$
$
Second claim information
2. Date claim made
Date of alleged error
Current Status/Date settled
Claim, suit or incident
Claimant(s)/Plaintiff(s)
Additional defendant(s) (if any)
Nature of claim and allegations
Name of insurance company
Date reported to insurance company
Loss
Expense
Amount reserved
$
$
Amount paid
$
$
Signatures
Signing this Supplement does not bind the Company to provide or the applicant to purchase the insurance.
It is understood that information submitted herein becomes a part of the application for insurance and is subject to the same
declarations, representations and conditions.
Must be signed by owner, principal, partner, executive officer or equivalent within 60 days of the proposed effective date.
Applicant's name
Title
Applicant’s signature
Date
Supplemental Claim Form for
Professional Liability Insurance
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Supplemental Claim Form for Professional Liability Insurance (Risk Placement Services, Inc.)

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Completed 23 November 2020

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