Elite Medical Malpractice Insurance

Claims

Name of Insured *

Phone Number *

Hospital / Clinic / Location of Incident *

Injury Details *

Speciality *

Nationality of Patient *

Date of Birth *

Claimant Solicitors / Lawyers *

Claimant's Relationship to Patient *

First Notification Received On *

Contact Email *

Policy Number *

Cause of Incident *

Date of Incidient/Loss *

Patient's Name *

Occupation *

Number of Dependants (only numbers) *

Claimant's Name (if different from patient name)

First Notification Received By *

Gender of Patient *

Marital status of patient *

Description of Facts/Injuries *

Claims related documents and Policy Documents
File 1:
File 2:
File 3: