Figure: 22 TAC §183.8(f)(9)

TEXAS STATE BOARD OF ACUPUNCTURE EXAMINERS

P.O. Box 2018
Austin, Texas 78768-2018

PROFESSIONAL LIABILITY CLAIMS REPORT

FILE ONE REPORT FOR EACH DEFENDANT ACUPUNCTURIST.

PART I. COMPLETE FOR ALL CLAIMS OR COMPLAINTS AND FILE WITH THE TEXAS STATE BOARD OF ACUPUNCTURE EXAMINERS WITHIN 30 DAYS FROM RECEIPT OF COMPLAINT OR CLAIM. INCLUDE COPY OF CLAIM LETTER AND/OR PLAINTIFF'S COMPLAINT.

1. Name and address of insurer:

______________________________________________

______________________________________________

2. Defendant acupuncturist:

______________________________________________

License number:_________________

3. Plaintiff's name:

______________________________________________

4. Policy number:

______________________________________________

5. Date claim reported to insurer/self-insured acupuncturist:

__________________

6. Type of complaint:___________ claim only ____________ lawsuit

7. Initial reserve amount after investigation:

______________________________________________

(If this is not determined within 30 days, report this data within 105 days of filing the Part I report with T.S.B.A.E.)

__________________________________         ___________________
            Person completing this report                                 Phone number

PART II. COMPLETE AFTER DISPOSITION OF THE CLAIM AS DEFINED IN 22 TAC §183.8(f), INCLUDING DISMISSALS OR SETTLEMENTS. FILE WITH T.S.B.A.E. WITHIN 105 DAYS AFTER DISPOSITION OF THE CLAIM. A COPY OF COURT ORDER OR SETTLEMENT AGREEMENT MAY BE USED AS PROVIDED IN 22 TAC §183.8(f).

8. Date of disposition:________________

9. Type of Disposition:

_______ (1) Settlement

_______ (2) Judgment after trial

_______ (3) Other (please specify)

____________________________________________________________

10. Amount of indemnity agreed upon or ordered on behalf of this defendant:

$ _______________________. Note: If percentage of fault was not determined by the court or insurer in the case of multiple defendants, the insurer may report the total amount paid for the claim followed by a slash and the number of insured defendants. (Example: $100,000/3)

11. Appeal, if known: _____Yes _____ No. If yes, which party:

____________________________________________________________

_______________________________            ________________________
Person completing this report                               Phone number