FORM F

							                                   FORM F
                  SURGICAL ASSISTANT LIABILITY CLAIMS REPORT
                                            File one report for each claim/action.
              This form is ONLY required if you have been named in a claim/action as any health professional.


APPLICANT:
Please complete the top portion of this form. Give the form to your liability carrier and request them to
complete and return the form to you.

Name: _____________________________________________________________________________

Current Mailing Address: _______________________________________________________________
                                                Street Address                     City              State      Zip
Date of Birth: ________________________
                              mm/dd/yyyy



LIABILITY CARRIER:
Please complete the bottom portion of this form and return the form to the surgical assistant applicant.

1. Name and address of Liability Carrier: __________________________________________________
                                                  __________________________________________________

2. Surgical Assistant for whom liability was carried: _________________________________________
3. Patient’s Name: ____________________________________________________________________
4. Plaintiff’s Name: (if different from patient) ______________________________________________
5. Policy Number: _____________________________ Type of Complaint: Claim _____ Suit _____
6. Date claim was reported to Insurer/Self-Insured Surgical Assistant: ________ Date of Injury ________
    Alleged Injury: ____________________________________________________________________

7. Status of claim/suit: (on this date) ______________________________________________________
8. Date of Disposition: ___________________________
9. Type of Disposition:
    _____ Pre-Trial Settlement _____ Post-Trial Settlement _____ Judgment after Trial _____ Dismissed

    Other: (please specify)
    __________________________________________________________________

10. Amount of indemnity agreed upon or ordered on behalf of this defendant: $___________________.
     Note: If the court or insurer in the case of multiple defendants did not determine percentage of fault,
           the insurer may report the total amount paid for the claim followed by a slash and the number
           of insured defendants (Example: $200,000/3).

11. Appeal: _____Yes _____No                   If yes, by which party: _________________________________

    Status of appeal: ___________________________________________________________________

    ______________________________________________                                          ___________________
             Name and Title of person completing form                                                Date


             REMINDER: Please return this completed form to the surgical assistant applicant.

SA 1/14/09