SUPPLEMENT
5
CLAIM OR CLAIM INCIDENT FORM
FULL NAME OF APPLICANT:
APPLICANT'S INSTRUCTIONS
THIS FORM IS TO BE COMPLETED IF THE APPLICANT OR ANY OTHER LAWYERS NAMED IN SUPPLEMENT 1 IS CURRENTLY OR HAS BEEN INVOLVED IN ANY CLAIM, POTENTIAL CLAIM, OR SUIT DURING THE LAST FIVE (5) YEARS AS INDICATED BY A "YES" ANSWER TO QUESTION 10.B, 10.C, or 10D PLEASE COMPLETE ONE FORM FOR EACH CLAIM
IF SPACE IS INSUFFICIENT TO ANSWER ANY QUESTION FULLY. PLEASE USE SEPARATE SHEET.
ENCLOSE SUMMONS AND COMPLAINT
PLEASE LEAVE NO BLANKS.
1.
Full name or individual(s) and name of firm involved in the claim:
a.
b.
c.
2.
Additional Defendants:
a.
b.
c.
3.
Full name of claimant:
4.
Date of alleged error:
5.
To what insurance company did you report this claim:
6.
Date reported to insurance company:
7.
Present status of claim: (Circle One)
Open
In Suit/Arbitration
Closed
Potential
8.
Total damages paid/outstanding:
$
9.
If pending
Amount asked in summons:
$
Claimant's Settlement demand:
$
Defendant's offer for Settlement:
$
10.
Description of claim - including likelihood of outcome if pending: (Please provide enough information to allow an evaluation including area of practice out of which claim arose.)
a.
Allegation upon which Claimant bases claim:
b.
Description of case and events:
c.
Describe steps taken to avoid similar claims:
Applicant hereby warrants that the statements set forth herein are true, complete and accurate and that there has been no attempt at suppression or misstatement of any material facts which are known, or should be known. Applicant agrees that this Supplemental Application shall become the basis for any coverage and part of any policy that is issued by the Company.
Date:
Signature:
Title:
