* Name

* Address

* Daytime Phone

* Evening Phone

Name of injured party:

Date of birth of injured party:

The Injured Party is:

Select Myself My Spouse My Child Friend Other"> Other relative Friend Other

If other, please explain:

This is a claim involving: (check all that apply)

Doctor(s)
Clinic
Hospital
Nursing Home
Other

Doctor(s) Name

Doctor(s) City/State

Clinic Name

Clinic City/State

Hospital Name

Hospital City/State

Nursing Home Name

Nursing Home City/State

Other Name

Other City/State

* The approximate date(s) of care, treatment, death or injury are: (include month and year)

Please provide a brief description of what you believe was an error or mistake:

Are there any long-term or permanent injuries or problems which you believe are a result of mistakes by healthcare providers?

Yes
No

If yes, please explain:

Have you lost income or the ability to work or earn?

Yes
No

If yes, please explain:

* Please enter the security code shown below:

* Name

* Address

* Daytime Phone

* Evening Phone

Name of injured party:

Date of birth of injured party:

The Injured Party is:

Select Myself My Spouse My Child Friend Other"> Other relative Friend Other

If other, please explain:

This is a claim involving: (check all that apply)

Doctor(s)
Clinic
Hospital
Nursing Home
Other

Doctor(s) Name

Doctor(s) City/State

Clinic Name

Clinic City/State

Hospital Name

Hospital City/State

Nursing Home Name

Nursing Home City/State

Other Name

Other City/State

* The approximate date(s) of care, treatment, death or injury are: (include month and year)

Please provide a brief description of what you believe was an error or mistake:

Are there any long-term or permanent injuries or problems which you believe are a result of mistakes by healthcare providers?

Yes
No

If yes, please explain:

Have you lost income or the ability to work or earn?

Yes
No

If yes, please explain:

* Please enter the security code shown below: