New Claims Reporting

REPORT OF NEW INCIDENT-CLAIM-SUBPOENA-LAWSUIT

* Indicates required field

Today's Date *

Email address for Insured Physician/Practitioner *

Name of Insured/Practitioner *

First

Last

Office Phone *

Cell Phone *

Preferred Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Date Papers Received *

Who Received The Papers And Where: *

PLEASE SEND THE PAPERS YOU RECEIVED TO:
CLAIMSREPORTING@ACADEMICGROUP.COM
Fax: +1 646-808-0605

Do you have office records? *

Yes No

PLEASE SEND RECORDS TO:
CLAIMSREPORTING@ACADEMICGROUP.COM
Fax: +1 646-808-0605

Age Of Patient *

First Date Of Treatment *

Date Of Occurrence /Incident *

Last Date Of Treatment *

Brief Description of Care/Incident: (Do not Include patient’s name) *

Please send us your office records for this patient

Submit

For questions:
Phone: +1 646-808-0588
Fax: +1 646-808-0605