E-Mail: OICFinancialConditions@wv.gov
Phone : 304-558-2100
FrmManage




1. NAME OF INSURER
2. CLAIM FILE IDENTIFICATION
3. NAIC COMPANY CODE
4. DATE OF INJURY
5. DATE REPORTED TO INSURER
6. DATE REOPENED
7. DATE CLOSED
8. ORIGINAL CLAIM ID NUMBER
9a. HOSPITAL OR ENTITY
9b. CITY
9c. STATE
9d. ZIP CODE
10a. NAME OF INDIVIDUAL HEALTH PROFESSIONAL INVOLVED IN CLAIM (LAST NAME)
10b. FIRST NAME
10c. MIDDLE NAME
10d. SUFFIX (MD, DO, ETC)
10e. INSURED'S LICENSE NUMBER
10f. CITY
10g. STATE
10h. ZIP CODE
11a. PROFESSIONAL CODE OF INSURED


11b.
SPECIALITY
CODE
No Surgery
No Surgery, Continued
Minor Surgery
Surgeons
Surgeons, Continued
Surgeons Class Group
Assistants & Techinicians
Dentists
Teaching Physicians & Surgeons
Misc. Medical Dentists Increased Limit Table
Misc Medical Druggists Increased Limits Table
12a. PLACE WHERE INJURY OCCURRED CODE
12b. CITY
12c. STATE
12d. ZIP CODE
13. WAS SUIT MEDIATED
14a. WAS SUIT APPEALED
14b. BY WHOM
15a. TOTAL DEFENDANTS INVOLVED IN CLAIM
15b. DERIVATIVE CLAIM CODE
N/A   YES   NO
N/A   YES   NO
N/A   Defendant   Plaintiff
16a. PLAINTIFF ATTORNEY'S NAME
16b. DEFENSE ATTORNEY'S NAME
17. NATURE AND SUBSTANCE OF CLAIM
18. DATE OF THIS PAYMENT OR CLOSURE
19. ACT OR OMMISSION
20. CLAIM DISPOSITION CODE
21. SETTLEMENT CODE
N/A   ACT   OMMISSION


22. Compliance with W. Va. Code §55-7B-6 Requirements.
22a. Was a 30 day notice served prior to filing suit?
N/A   YES   NO
22b. Was a screening certificate of merit obtained?
N/A   YES   NO
22c. If not, was a statement in lieu of the screening certificate of merit provided?
N/A   YES   NO
22d. Was a response by claimant provided within 30 days?
N/A   YES   NO
22e. Was the health care provider afforded the opportunity for pre-litigation mediation?
N/A   YES   NO
23a. COUNTY
23b. DOCKET NUMBER
23c. DATE SUE WAS FILED
24a. INDEMNITY PAID BY YOU ON BEHALF OF THIS DEFENDANT
24b. ECONOMIC DAMAGES
24c. NON-ECONOMIC DAMAGES
24d. PUNITIVE DAMAGES
25. LOSS ADJUSTMENT EXPENSES PAID
26. STRUCTURED SETTLEMENT
N/A   YES   NO
27. PERSON RESPONSIBLE FOR REPORT
28. TELEPHONE NUMBER
29. ADDRESS
30. E-MAIL ADDRESS