Incident Form Instructions

If a specific claim is made against you, or you receive a summons, please immediately report it to us. In most cases there is a response requirement date and missing that date can jeopardize your case.

If you receive a lawsuit or notice of a claim/investigation or have any correspondence to go along with this report, please attach the documents using the link at the bottom of the form. There may be response requirements and missing that date can jeopardize your case.

This form is secure and non-discoverable.

Please complete the form below to report an incident. If you need immediate Claims assistance, please call our office at (206) 343-7300. Our office hours are Monday-Friday, 8am-5pm, PST.

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Incident Form

(* Indicates a required field)

Contact Information (person completing form)

Your full name

Professional designation

Your title

Name of clinic/group/hospital

Your relation to the provider

Your phone number

Phone number type

Would you like a call back?

Yes

Address 1

Address 2

CITY

STATE

ZIP/POSTAL CODE

Your e-mail address

Involved Providers

Involved providers:

Provider 1

Involved provider

Remove

Name of involved provider

Is the provider insured with PI/PI RRG?

Yes

Involved provider's phone number

Would you like a call back?

Yes

Address same as above

Address 1

Address 2

CITY

STATE

ZIP/POSTAL CODE

Involved provider's e-mail address

Patient/Claimant

Patient/claimant full name

Date of incident

Patient/claimant age

If patient/claimant is represented, name of patient's attorney

Event

Reason for report

Other report reason

Attach any correspondence received

Choose File

Enter a brief explanation (limit 1000 characters)

Would you like a copy of this submission?

Note

Please note that the "Click here to print to PDF" functionality is temporarily down. We will repair this feature as soon as we can.