Notice of Claim or Potential Claim

Claimant Information

Last Name *

First Name *

Address *

City *

State *

ZIP Code

Marital Status

Sex

DOB *

Occupation

Claimant Type

Claimant Type Other

Event Details

Who Reported the Event?

Where did the event occur (setting)? *

Date of Event *

Has this been previously reported? Yes No

Event Site and Address *

Description *

CRICO Insured Information

Please complete the fields in this section with the name and email address for each insured involved in this event.

Type Employee Physician

Name/Org *

Contact Info *

Position & Insured Institution

Effective Date

Employee Start Date *

Employee End Date

If the employee no longer works here, enter the end date as well.

Type Employee Physician

Name/Org

Contact Info

Position & Insured Institution

Effective Date

Employee Start Date *

Employee End Date

If the employee no longer works here, enter the end date as well.

Type Employee Physician

Name/Org

Contact Info

Position & Insured Institution

Effective Date

Employee Start Date *

Employee End Date

If the employee no longer works here, enter the end date as well.

Additional Named Insureds

Case Type

Type * Potential Claim Claim Suit Board Complaint Legal Assist

Enter up to six attachments totalling no more than 10 MB for one of the following.

For a claim, attach the claim letter.
For a suit, attach the summons and complaint.
Provide relevant documents for a potential claim, legal assist, e.g. regulatory complaint, subpoena, request for medical information, etc.

Additional Documentation

Claim Letter

Summons & Complaint

Prepared By *

Email *

Title

Date

Phone Number

Claim Manager

If needed, see the CRICO Claim team page to select the proper team that will support this case. The team's manager will be instantly alerted when you submit the form.CRICO Team * Team 1 Stephen Morey Team 2 Robert Guman Team 3 Amy Germond Team 4 Kerri Sanclemente

This report is to be used as a notice of specific circumstances involving a particular person or property. It is a confidential preparation for litigation. It is not a part of the patient’s record.

Issues with the Form?

Proactive Tips:

Form to Submit a New Case

Claimant Information

Event Details

CRICO Insured Information

Please complete the fields in this section with the name and email address for each insured involved in this event.

Case Type

Claim Manager

Issues with the Form?

Proactive Tips:

Form to Submit a New Case

Claimant Information

Event Details

CRICO Insured Information

Please complete the fields in this section with the name and email address for each insured involved in this event.

Case Type

Claim Manager

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Patient Safety & Claims