• Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
Claims Reporting Form

GENERAL INFORMATION
*Firm Name:
Required
*Phone:
000-000-0000
*Lawyer:
Required
*EMail:
Required
*Person or company making claim:
Required
Chronological summary of your representation and/or relationship to the person or company making the claim:
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The act, error or omission alleged against you including the date if known:
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How and when you became aware of the act, error or omission:
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The injury or damage that has been alleged or may result, including your estimate of value:
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Recommendations you have for repairing the claim or incident: (we typically do not need copies of all the medical records on a claimant or your entire file at this initial stage):
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If an attorney has been retained by the claimant, provide name, address, phone and e-mail:
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Summary of any actions you have undertaken with regard to the claim since your receipt of the claim:
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Enclose a copy of the complaint if a lawsuit has been filed.
Required
Accepted file formats: .bmp | .doc | .docx | .jpg | .jpeg | .pdf | .png | .ppt | .pptx | .txt
Required
Accepted file formats: .bmp | .doc | .docx | .jpg | .jpeg | .pdf | .png | .ppt | .pptx | .txt
Required
Accepted file formats: .bmp | .doc | .docx | .jpg | .jpeg | .pdf | .png | .ppt | .pptx | .txt
Required
Accepted file formats: .bmp | .doc | .docx | .jpg | .jpeg | .pdf | .png | .ppt | .pptx | .txt

The above information has been reviewed and is certified to be correct.
I understand that the information submitted on this application becomes part of the policy for professional liability insurance and is subject to the same terms and conditions.
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323 West Main Street, Suite 600  |  Louisville, KY 40202  |  Ph. 502-568-6100  |  Fax 502-568-6103

Disclaimer: The contents of this Web site are intended for general information purposes only and should not be construed as legal advice or legal opinion on any specific facts or circumstances. It is not the intent of this Web site to establish an attorney’s standard of due care for a particular situation. Rather, it is our intent to advise our policyholders to act in a manner which may be well above the standard of due care in order to avoid claims having merit, as well as those without merit. In the event any statement on the Web site differs from a statement in an issued policy the policy will control.

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