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					Physicians      (1)           (2)          (2a)               (3)                 (4)          (4a)                 (5)                      (5a)                        (5b)                       (6)                       (6a)                       (6b)
                                                                                                                                                                                                                                             # of medical malpractice
                                                                                                          # of medical malpractice # of medical malpractice                               # of medical malpractice                               incidents reported
                                                      Practice location(s)                                  court judgments and      court judgments and       # of medical malpractice           settlements       # of medical malpractice       by the insured
                                                       name of city/town                                     arbitration awards,      arbitration awards,       claims closed without        in the past 5 years,            claims             in the past 5 years,
                                         If Group,          or zip code                     # of years       in the past 5 years,     in the past 5 years,          a loss payment           [not included in (5)]     currently open and       which did not result
  Policy                 Individual (I) # Providers    (fill-out 1 line per   # of years    in practice   in which a payment was in which no payment was          in the past 5 years     in which a payment was      pending against the             in a claim
  Count      Specialty   or Group (G) in Group         practice location)     in practice      in NJ       awarded to the plaintiff awarded to the plaintiff     [not included in (5a)]    awarded to the plaintiff         insured          [not included in (5)-(6a)]

    1
    2
    3
    4
    5
    6
    7
    8
    9
   10
   etc.
          (7)                   (7a)                    (7b)              (8)        (8a)       (8b)      (8c)       (8d)      (8e)
     $ amount of         $ amount of loss
incurred loss for all adjustment expense for     $ amount of loss
medical malpractice all medical malpractice adjustment expense for
  court judgments,       court judgments,    all medical malpractice               Expiring   Renewal
arbitration awards,     arbitration awards,       claims, closed       Effective    policy     policy  $ amount       %
   and settlements        and settlements            without a          date of    premium    premium of premium of premium Reason for      Reason codes for
 in the past 5 years       included in (7)         loss payment         policy        $          $     increase   increase   increase      premium increases

                                                                                                                                         a - filed rate increase
                                                                                                                                         b - new claims
                                                                                                                                         c - change in specialty
                                                                                                                                         d - change in class
                                                                                                                                         e - change in practice
                                                                                                                                             location
                                                                                                                                         f - other
Surgeons      (1)           (2)          (2a)                (3)                (4)          (4a)


                                                    Practice location(s)
                                                     name of city/town
                                       If Group,          or zip code                     # of years
 Policy                Individual (I) # Providers    (fill-out 1 line per   # of years    in practice
 Count     Specialty   or Group (G) in Group         practice location)     in practice      in NJ

   1
   2
   3
   4
   5
   6
   7
   8
   9
  10
  etc.
          (5)                      (5a)                        (5b)                        (6)

# of medical malpractice # of medical malpractice                               # of medical malpractice
  court judgments and      court judgments and       # of medical malpractice           settlements
   arbitration awards,      arbitration awards,       claims closed without        in the past 5 years,
   in the past 5 years,     in the past 5 years,          a loss payment           [not included in (5)]
in which a payment was in which no payment was          in the past 5 years     in which a payment was
 awarded to the plaintiff awarded to the plaintiff     [not included in (5a)]    awarded to the plaintiff
         (6a)                        (6b)                    (7)                    (7a)
                         # of medical malpractice       $ amount of          $ amount of loss
                             incidents reported     incurred loss for all adjustment expense for
# of medical malpractice       by the insured       medical malpractice all medical malpractice
         claims             in the past 5 years,     court judgments,        court judgments,
   currently open and       which did not result    arbitration awards,     arbitration awards,
  pending against the             in a claim          and settlements         and settlements
        insured          [not included in (5)-(6a)] in the past 5 years        included in (7)
         (7b)                (8)        (8a)       (8b)      (8c)       (8d)      (8e)

    $ amount of loss
adjustment expense for
all medical malpractice               Expiring   Renewal
     claims, closed       Effective    policy     policy  $ amount       %
        without a          date of    premium    premium of premium of premium Reason for
      loss payment          policy       $          $     increase   increase   increase
   Reason codes for
  premium increases

a - filed rate increase
b - new claims
c - change in specialty
d - change in class
e - change in practice
    location
f - other
Podiatrists      (1)           (2)          (2a)                (3)                (4)          (4a)


                                                       Practice location(s)
                                                        name of city/town
                                          If Group,          or zip code                     # of years
  Policy                  Individual (I) # Providers    (fill-out 1 line per   # of years    in practice
  Count       Specialty   or Group (G) in Group         practice location)     in practice      in NJ

    1
    2
    3
    4
    5
    6
    7
    8
    9
   10
   etc.
          (5)                      (5a)                        (5b)                        (6)

# of medical malpractice # of medical malpractice                               # of medical malpractice
  court judgments and      court judgments and       # of medical malpractice           settlements
   arbitration awards,      arbitration awards,       claims closed without        in the past 5 years,
   in the past 5 years,     in the past 5 years,          a loss payment           [not included in (5)]
in which a payment was in which no payment was          in the past 5 years     in which a payment was
 awarded to the plaintiff awarded to the plaintiff     [not included in (5a)]    awarded to the plaintiff
         (6a)                        (6b)                    (7)                    (7a)
                         # of medical malpractice       $ amount of          $ amount of loss
                             incidents reported     incurred loss for all adjustment expense for
# of medical malpractice       by the insured       medical malpractice all medical malpractice
         claims             in the past 5 years,     court judgments,        court judgments,
   currently open and       which did not result    arbitration awards,     arbitration awards,
  pending against the             in a claim          and settlements         and settlements
        insured          [not included in (5)-(6a)] in the past 5 years        included in (7)
         (7b)                (8)        (8a)       (8b)      (8c)       (8d)      (8e)

    $ amount of loss
adjustment expense for
all medical malpractice               Expiring   Renewal
     claims, closed       Effective    policy     policy  $ amount       %
        without a          date of    premium    premium of premium of premium Reason for
      loss payment          policy       $          $     increase   increase   increase
   Reason codes for
  premium increases

a - filed rate increase
b - new claims
c - change in specialty
d - change in class
e - change in practice
    location
f - other
Nurses      (1)           (2)          (2a)                (3)                (4)          (4a)


                                                  Practice location(s)
                                                   name of city/town
                                     If Group,          or zip code                     # of years
Policy               Individual (I) # Providers    (fill-out 1 line per   # of years    in practice
Count    Specialty   or Group (G) in Group         practice location)     in practice      in NJ

  1
  2
  3
  4
  5
  6
  7
  8
  9
 10
 etc.
          (5)                      (5a)                        (5b)                        (6)

# of medical malpractice # of medical malpractice                               # of medical malpractice
  court judgments and      court judgments and       # of medical malpractice           settlements
   arbitration awards,      arbitration awards,       claims closed without        in the past 5 years,
   in the past 5 years,     in the past 5 years,          a loss payment           [not included in (5)]
in which a payment was in which no payment was          in the past 5 years     in which a payment was
 awarded to the plaintiff awarded to the plaintiff     [not included in (5a)]    awarded to the plaintiff
         (6a)                        (6b)                    (7)                    (7a)
                         # of medical malpractice       $ amount of          $ amount of loss
                             incidents reported     incurred loss for all adjustment expense for
# of medical malpractice       by the insured       medical malpractice all medical malpractice
         claims             in the past 5 years,     court judgments,        court judgments,
   currently open and       which did not result    arbitration awards,     arbitration awards,
  pending against the             in a claim          and settlements         and settlements
        insured          [not included in (5)-(6a)] in the past 5 years        included in (7)
         (7b)                (8)        (8a)       (8b)      (8c)       (8d)      (8e)

    $ amount of loss
adjustment expense for
all medical malpractice               Expiring   Renewal
     claims, closed       Effective    policy     policy  $ amount       %
        without a          date of    premium    premium of premium of premium Reason for
      loss payment          policy       $          $     increase   increase   increase
   Reason codes for
  premium increases

a - filed rate increase
b - new claims
c - change in specialty
d - change in class
e - change in practice
    location
f - other

				
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