* indicates a required field
Full name of policy holder: *
Full name of physician: *
Address of physician involved in action:
Street address: *
Additional address:
City: *
State: *
Zip code: *
Name of claimant: *
Summary of allegations: *
Case concluded by: *
Judgment FOR physician Judgment AGAINST physician Settlement in OR out of court
Date and amount of: *
Judgment
Or
Settlement
# Insured's contribution: *
# - Do not include the cost of defense in this amount and if the "insured" is other than an individual physician, please indicate the amount charged against the physician on whom this report is submitted
Provide the company name (or entity), name of individual, address, phone number and email address for the individual submitting the report.
Company (or entity): *
Individual submitting form: *
Telephone number: *
Your email address: *
Confirm your email address: *
This form uses Huggins' Email Form Script