SUPPLEMENTAL CLAIM INFORMATION

NOTE: This form is to be completed by Applicant who has been involved in any claim or suit or is aware of an incident which may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM/SUIT OR INCIDENT.
 

Submitted by:

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Agency:

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Mailing Address:

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City:

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State:

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Zipcode:

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Phone Number / Area Code:

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Fax:

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Email Address:

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Applicant`s Instructions:
1. Complete the online form including the claim form if applicable
2. If you have a CV.(resume) please email to pbs@pbsinsurance or fax to 502-254-1056
3. Please DO NOT complete the application earlier than 60 days before the proposed effective date of coverage.

Applicant Name:
Claimant Name:
Name of Individual(s) at your firm/Company involved in Claim:
Indicate whether: Claim/Suit Incident
Date of alleged error: / /
Date claim made against applicant:
Additional defendants:
   
Current Disposition of claim:  
DISMISSED (Action dropped without any payment to claimant or Stature of Limitations has expired)
ABANDONED (no activity from claimant for over 3 years)
WON by defense  
WON by claimant
  Court judgment, or Out of court settlement
  Total Paid $ Amount Paid on your behalf $
Open Claimant's settlement demand $
  Defendant's offer for settlement? $ Insurer's loss reserve $
Name of Insurer:
   
Description of claim: (Provide enough information to allow evaluation)
Alleged act, error or omission upon which Claimant bases claim:
Description of cases and events:
Description of the type and extent of injury or damage allegedly sustained:
If a medical claim provide type of injury claimed:  
Emotional Only  
Temporary Disability  
Death  
Cosmetic  
Permanent Disability  
Other (Please describe)
     
     
  You must provide your Name, Title and Today's Date in order to submit this quote request.
 
/ /
Name of Applicant Title Date

 
* Completion of these forms does not bind the applicant or PBS Insurance Underwriting Corporation and affiliates or the Insurance Company and/or the Underwriting Manager to complete the Insurance.