Regulation .04 Required Information.

Name of insurer;

Name of insurer group;

Claim file identification (ID);

Name of person completing the form;

Telephone number, including area code, of person completing the form;

Date form completed;

Date of injury;

Date injury reported to insurer;

Date claim closed;

Whether the claim was previously reported;

Age of injured person at time of injury;

Gender of injured person at time of injury;

Type of injury, such as wrongful death, permanent disability, or other bodily injury;

Description of injury;

Name of health facility where injury occurred;

Type of medical professional liability policy, such as occurrence, claims made—basic, or claims made—tail;

Type of patient, such as inpatient, emergency room outpatient, or other outpatient;

Physician Insurance Services Office Incorporated (ISO) classification or equivalent classification;

Type of health care provider, such as physician-no surgery, surgeon, psychiatrist and related specialties, nurse, nurse midwife, optometrist, pharmacist, chiropractor, podiatrist, psychologist, dentist, hospital, other health care facility, or nurse anesthetist;

Physician and surgeon classification, including name of specialty;

Health care provider name;

Health care provider license number;

Policy limits for each claim or medical incident;

Policy limits for annual aggregate;

If known, the facility, office, or county where the injury occurred;

Whether the claim is a zero payment claim file;

Full name and location of the court where the suit was filed and the case was tried;

Case or docket number;

Whether settlement was reached or award was made at one of the following stages:

If settlement was reached or award was made by court verdict, whether the result was:

If there was no final judgment or settlement, the date of the final disposition;

If there was no final judgment or settlement, the reason for the final disposition;

If case did go to trial, whether the case was tried by a jury or tried by a judge;

Total amount paid to the claimant;

Amount paid by the insurer;

Amount paid by the insured due to retention or deductible;

If known, the amount paid by an excess carrier;

If known, the amount paid by the insured due to settlement or award in excess of policy limits, not including deductible or retention amounts;

If known, the amount paid by the insurer due to settlement or award in excess of policy limits, not including deductible or retention amounts;

If known, the amount paid by other defendants or contributors;

A summary of the occurrence from which the claim or action arose;

A description of the misdiagnosis or alleged misdiagnosis made, if any, of the patient's actual condition;

A description of the procedure giving rise to the claim;

A description of the principal injury giving rise to the claim;

The amount of past medical expenses claimed by the plaintiff;

The amount of future medical expenses claimed by the plaintiff;

The amount of past lost wages claimed by the plaintiff;

The amount of future lost wages claimed by the plaintiff;

The amount of noneconomic damages claimed by the plaintiff;

The amount of other damages claimed by the plaintiff;

Whether a structured settlement or periodic payment was used, and if so:

If a neutral expert was used, the findings of a neutral expert witness regarding future medical expenses;

If a neutral expert was used, the findings of a neutral expert witness regarding future loss of earning;

If case was tried to verdict:

The total allocated loss adjustment expense;

Of the total allocated loss adjustment expense, the amount representing fees paid to defense counsel;

Of the total allocated loss adjustment expense, the amount of expenses not included in the defense counsel fees;

Whether there was a claim made for extra contractual damages;

The amount claimed for extra contractual damages;

Whether a suit was filed or claim was made for extra contractual damages; and

Where the suit for the extra contractual damages claim was filed, including: