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. PROFESSIONAL CODE OF INSURED


9b.
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
10a. PLACE WHERE INJURY OCCURRED CODE
10b. CITY
10c. STATE
10d. ZIP CODE
11. WAS SUIT MEDIATED
12a. WAS SUIT APPEALED
12b. BY WHOM
13a. TOTAL DEFENDANTS INVOLVED IN CLAIM
13b. DERIVATIVE CLAIM CODE
N/A   YES   NO
N/A   YES   NO
N/A   Defendant   Plaintiff
14a. PLAINTIFF ATTORNEY'S NAME
14b. DEFENSE ATTORNEY'S NAME
15. NATURE AND SUBSTANCE OF CLAIM
16. DATE OF THIS PAYMENT OR CLOSURE
17. ACT OR OMMISSION
18. CLAIM DISPOSITION CODE
19. SETTLEMENT CODE
N/A   ACT   OMMISSION


20. Compliance with W. Va. Code §55-7B-6 Requirements.
20a. Was a 30 day notice served prior to filing suit?
N/A   YES   NO
20b. Was a screening certificate of merit obtained?
N/A   YES   NO
20c. If not, was a statement in lieu of the screening certificate of merit provided?
N/A   YES   NO
20d. Was a response by claimant provided within 30 days?
N/A   YES   NO
20e. Was the health care provider afforded the opportunity for pre-litigation mediation?
N/A   YES   NO
21a. COUNTY
21b. DOCKET NUMBER
21c. DATE SUIT WAS FILED
22a. INDEMNITY PAID BY YOU ON BEHALF OF THIS DEFENDANT
22b. ECONOMIC DAMAGES
22c. NON-ECONOMIC DAMAGES
22d. PUNITIVE DAMAGE
23. LOSS ADJUSTMENT EXPENSES PAID
24. STRUCTURED SETTLEMENT
N/A   YES   NO
25. PERSON RESPONSIBLE FOR REPORT
26. TELEPHONE NUMBER
27. ADDRESS
28. E-MAIL ADDRESS