NOTICE OF LOSS/INCDIENT REPORT
Caitlin-Morgan Insurance Services
Attention: Lara Engelking
5875 Castle Creek Parkway N Drive, Suite 215
Indianapolis, IN 46250
Phone: 317-575-4440, ext: 240
Fax: 317-575-4454
 
Person Making the Report:
 
First Name
 
 
Last Name
 
 
Phone Number
 
 
Reason Reported:
 
 
Date Suit Served
 
 
Date Suit Filed
 
 
Insured:
Parent Company
 
 
Policy Number
 
 
Parent Company Contact
 
 
Certificate Number
 
 
Parent Company Contact Phone
 
 
Policy Period
 
 
Parent Company Contact Address
 
 
Email*
 
 
Claimant:
Claimant Name
 
 
Claimant Date of Birth
 
 
Claimant Address
 
 
Claimant Gender
 
 
Claimant Phone
 
 
Claimant SSN#
 
 
Claimant Attorney
 
 
Claimant Marital Status
 
 
Claimant Attorney Phone
 
 
Claimant Admission Diagnosis
 
 
Incident Data:
Date of Loss/Incident
 
 
Date of Admission
 
 
 
Facility Name
 
 
Date Of Last Treatment/Discharge
 
 
 
Facility Address
 
 
 
Facility Contact
 
 
Facility Phone
 
 
 
Medical Condition at Discharge
 
 
 
Description of Incident
 
 
Injury