Malpractice Info | Cirrus Medical Network

SUPPLEMENTAL CLAIMS INFORMATION FORM

(Complete one form for each claim)

Type of Claim
- Medical Director
- Medical Malpractice Claim
Name of applicant/named insured:
First Last
Name of other parties or defendants named in suit:
Date of alleged error or occurrence, or contact date:
Date claim was made:
DD slash MM slash YYYY
Name of claimant:
Name of Insurance Company handling your claim:
Present status of claim or final disposition:
Choose One:
- CLOSED
- OPEN
Defense costs paid to date inclusive of any deductible:
If closed, total loss paid, inclusive of any deductible:
If claim is open or pending, what are the insurers reserves?
Defense: Loss:
Description of case and events including allegatioins and assessment of liability:
Claimants last settlement demand:
Date
MM slash DD slash YYYY
Signature

Next Step: Sign the Provider Agreement

The Telehealth Assessment Provider Agreement, or simply "Provider Agreement", covers the terms and conditions between Cirrus Medical Network and Physicians/Providers. Please review and complete the agreement, along with the compensation table.

Provider Agreement

Company	Policy Number	Term	Limits of Liability	Retro Date

APPLICATION TO ADD A PHYSICIAN, SURGEON TO AN ENTITY POLICY/QUOTE

Entity Info:

Physician's Personal Information

Treating Physician Services Information

Medical Director Services Information

Prior/Other Insurance Information

Claim Information

Applicant Warranty:

SUPPLEMENTAL CLAIMS INFORMATION FORM

Next Step: Sign the Provider Agreement