1.
Name of Insurer: Enter name of company or self-insurer reporting this claim.
2.
Claim File Identification: Assign a distinguishing claim file identification number to each claim report. This number must be a sufficient identification to enable tracing of a particular claim.
3.
NAIC Company Code: Assigned NAIC code to insurance companies, self insurers contact the Offices of the Insurance Commissioner.
4.
Date of Injury: Date of principal injury or alleged injury.
5.
Date Reported to Insurer: Date when claim was first reported to insurer and claim opened.
6.
Date Reopened: Date claim was reopened if applicable.
7.
Date Closed: Date claim was closed.
8.
Original Claim ID Number if claim was reopened: If claim is reopened, please enter the original claim identification number used when claim was originally filed with the Department.
9a.
Professional Code of Insured: Select appropriate code from the dropdown for the named insured.
9b.
Specialty Code: Select appropriate specialty code.
10a.
Place Where Injury Occurred: Select the appropriate code from the dropdown for the type or area of facility where the principal injury occurred.
10b.
City: Enter city for place of injury coded in 10a.
10c.
State: Enter two letter state abbreviations for place of injury coded in 10a.
10d.
Zip: Enter zip code for place of injury coded in 10a.
11.
Was Suit Mediated: Select Yes, No, or N/A.
12a.
Was Suit Appealed: Select Yes, No, or N/A.
12b.
By Whom: Check Plaintiff or Defendant. If not applicable, check N/A.
13a.
Total Defendants Involved in Claim: Enter total number of defendants (persons and institutions other than John Does) involved in claim.
13b.
Derivative Claim Code: Select the appropriate code if there was a derivative claim made on behalf of someone other than the medically injured.
14a.
Plaintiff Attorney’s Name: Enter name of attorney.
14b.
Defense Attorney’s Name: Enter name of attorney.
15.
Nature and Substance of Claim: Give a description of actions and circumstances causing the claim.
16.
Date of this payment or closure: Enter date of payment or date claim was closed. When reporting a reopened case, enter new closure date.
17.
Act or Omission: Select either Act, Omission, or N/A.
18.
Claim Disposition Code: For all claims, select the final method of claim disposition from the dropdown.
19.
Settlement Code: If the claim disposition code from #18 equals (a) Settlement, then select the applicable settlement code from the dropdown.
20.
Compliance with W. Va. Code §55-7B-6 Requirements: Select either Yes, No, or N/A for each question on #20.
21a.
County: Enter county where suit was filed.
21b.
Docket Number: Enter docket number.
21c.
Date Suit Was Filed: Enter date suit was filed.
22a.
Total Paid by you on Behalf of this Defendant: Enter total paid by you on behalf of this defendant.
22b.
Economic Damages: From the amount entered on line 22a the amount of damages from pecuniary harm including, without limitation, medical damages and those damages arising from lost wages and lost earning capacity.
22c.
Non-Economic Damages: From the amount entered on line 22a the amount of damages arising from non-pecuniary harm including, without limitation, pain, suffering, mental anguish, inconvenience, physical impairment, disfigurement, loss of capacity to enjoy life, and loss of consortium but shall not include punitive damages.
22d.
Punitive Damages: From the amount entered on line 22a the amount of punitive damages intended to punish or deter willful, wanton, or malicious misconduct.
23.
Loss Adjustment Expense Paid: Enter all costs incurred in the investigation, settlement and recording of the claim.
24.
Structured Settlement: Select Yes, No, or N/A.
25.
Person Responsible for Report: Enter name of person responsible for completed report.
26.
Telephone Number: Enter business telephone number of person responsible for completed report.
27.
Address: Enter business address of person responsible for completed report.
28.
E-mail Address: Enter e-mail address of person responsible for completed report.