Claim/Potential Claim/Bar Complaint Supplement If you are human, leave this field blank.Please fill in the form and click on Submit.Firm Name: Name of the Attorney involved in the Claim or Incident: Name of the Claimant(s): Date of Alleged Error: Date Reported to Insured: Name of Insurance Company Reported to: Status of Claim/Potential Claim/Bar Complaint:ClaimPotential Claim/IncidentBar ComplaintOpenIn SuitClosedIf OPEN:$ of Indemnity Reserve: $ of Expense Reserve: If CLOSED:Date Closed:$ of Settlement Claim Paid:$ of Expenses Paid:Description of the Claim/Potential Claim/Disciplinary Issue: If a Bar Complaint or a disciplinary matter has been filed, was the matter dismissed? YesNoIf not dismissed, provide us with the current status.Please type your signature:DateSubmit
