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MEDICAL PROFESSIONAL LIABILITY INSURANCE CLAIM REPORT Insurance Mo Form
Reporting this claim. The NAIC Group Company Code is assigned to insurance companies by the NAIC. Recovery delayed. Permanent Loss of fingers loss or damage to organs. Includes nondisabling injuries. NAME OF INSURER NAIC GROUP COMPANy CODE 1B. CLAIM FILE IDENTIFICATION 2A. DATE OF INjURy 2B. DATE REPORTED TO INSURER 2C. THE NATURE AND SUBSTANCE OF CLAIM PROvIDE ALL AvAILABLE INFORMATION 10B. THE CONDITION FOR wHICH TREATMENT wAS SOUGHT 10C. INJURED PERSONS NAME LAST NAME 3D. MIDDLE INITIAL 7E....
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