Provider OnBoarding | Claims History

Home
Instructions
OnBoarding
Attachments

Section VIII - Claims History

Claims
COI

NO CLAIMS Please sign and date at bottom

Claim

Date of alleged incident:

Date lawsuit filed:

Carrier at the time of alleged allegation

Name of Court and case number

Status of Case: (with reference to you specifically)

Notice of Claim Filed:

Pending Before Malpractice Panel:

Pending in Court:

Closed Without Payment:

Pre-Trial Settlement:

Verdict for Defendant:

Verdict for Plaintiff:

What was/is your status:

Sole Defendant

Co-Defendant

Other

Past 10 years Certificates of Insurance ("COI")

Carrier

Address

Phone Number

Fax #

Policy Number

Effective Dates

Amounts

Occurrence/Claims Made

I understand information submitted herein becomes part of my Application for staff appointment/credentialing and may also be used in future credentialing.

Applicant Name:

Applicant Signature:

Date:

Save & Continue

Progress List

Pre-Application Questions Completed
Basic Details In Progress
Clinical Work History Missing Info
Education Completed
CME Not Started
Licenses Not Started
Certifications Not Started
Professional Liability Insurance Not Started
Claims History Not Started
References Not Started
Attetation Questions Not Started
Background Check Not Started
Acknowledgments Not Started
Confidentiality Agreement Not Started
Information Release Not Started

Copyright © KontactIntelligence, Inc. All Right Reserved