Legal Malpractice Claim Report Form PDF Details

When navigating the complexities of legal practice, professionals sometimes encounter unexpected challenges, including allegations of malpractice. The Legal Malpractice Claim Report form, a critical document issued by the Missouri Department of Insurance, Financial Institutions, and Professional Registration, serves as a comprehensive tool for reporting claims of legal malpractice. This form is meticulously designed to capture essential information ranging from the basics such as the insurer’s name, claim file number, and the insured’s location, to more nuanced details like the status of the claim, the nature of the error or omission, and the amount involved in the claim. Divided into several sections for systematic reporting, the form ensures that each claim is documented with precision. Section A solicits general information about the claim, including the insurer’s identity and the specifics of the claim’s status, while Section B delves into claims that are already closed, spotlighting the claim’s disposition and financial aspects. Section C, applicable to all claims, zeroes in on the legal dimensions by requiring details about the area of law, the major activity during which the error occurred, and the nature of the alleged error or omission. This form is not just a bureaucratic requirement; it is a vital instrument for maintaining the integrity of the legal profession and safeguarding the interests of both legal practitioners and their clients.

QuestionAnswer
Form NameLegal Malpractice Claim Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names375 1662 claims reporting form

Form Preview Example

MISSOURI DEPARTMENT OF INSURANCE,

MAIL TO:

STATISTICAL SECTION

FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION

P.O. BOX 690

LEGAL MALPRACTICE CLAIM REPORT

JEFFERSON CITY, MO 65102-0690

SEE INSTRUCTIONS ON REVERSE

 

SECTION A

 

1. INSURER’S NAME

2. NAIC GROUP AND COMPANY CODE

3. INSURER CLAIM FILE NUMBER

4. INSURED’S CITY, STATE, ZIP CODE

 

 

 

A. New Claim

 

C. Corrected New Claim

5.

5.

STATUS OF THIS CLAIM

 

 

 

 

B. Closed Claim

 

D. Corrected Closed Claim

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

6.

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

01 - 1,000,000 or more

03 - 100,000 to 499,999

05 - Less than 49,999

7.

7.

POPULATION CODE

 

02 - 500,000 to 999,999

04 - 50,000 to 99,999

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

HOW MANY LAWYERS WERE

 

A. One

 

C. 6 to 30

 

8.

 

 

 

 

 

INSURED ON THE POLICY?

 

B. 2 to 5

 

D. Over 30

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

HOW MANY YEARS HAD THE INSURED BEEN ADMITTED TO

A. Under 4 years

C. Over 10 years

9.

 

 

PRACTICE AT THE TIME OF THE ALLEGED ERROR?

 

B. 4 to 10 years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

WHAT TYPE OF LAW OFFICE IS THE

 

A. Legal Clinic

 

C. Private Practice

 

10.

 

 

 

 

 

INSURED A MEMBER OF?

 

 

B. Legal Aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

WHAT IS THE INSURED’S RELATIONSHIP

A. Free legal service

 

 

C. Client other than A or B

11.

 

 

 

 

TO THE CLAIMANT?

 

 

B. Member pre-paid legal plan

D. Non-client

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

DID THE CLAIM ARISE AFTER THE INSURED MADE

 

 

 

 

 

12.

 

A = YES

 

B = NO

 

 

AN ATTEMPT TO COLLECT A FEE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

DID THIS CLAIM ARISE FROM AN AREA OF LAW:

 

A. Normal to the insured’s practice

 

13.

 

B. Not normal to the insured’s practice

 

 

 

 

 

 

 

 

C. Not applicable

 

 

 

 

 

 

 

 

14. MO/YR

 

 

 

 

 

15. MO/YR

14.

DATE OF OCCURRENCE

 

 

 

 

 

 

15. DATE FIRST REPORTED TO INSURER

 

 

 

 

 

 

 

 

 

 

 

 

SECTION B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. MO/YR

16.

DATE THIS CLAIM CLOSED OR DISPOSED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

CLAIM DISPOSITION

 

 

 

 

 

 

 

 

 

17.

 

A. Before filing suit or demanding hearing

 

 

 

 

F. During appeal

 

 

 

B. Before trial or hearing

 

 

 

 

 

G. After appeal

 

 

 

 

 

 

 

 

 

 

 

C. During trial or hearing

 

 

 

 

 

H. Claim or suit abandoned

 

 

D. After trial or hearing but before judgment or decision

 

I. During review panel or non-binding arbitration

 

 

E. After judgment or decision but before appeal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

18.

What amount was paid to the claimant (including the deductible)?

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

19.

What amount was paid for loss expenses (including the deductible)?

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

20.

What reserve amount was established for loss payment?

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

21.

What reserve amount was established for loss expense?

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

22.

What was the amount of the insured’s deductible?

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23

23.

AREA OF LAW (See instructions for code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

25.MAJOR ACTIVITY CODE (See instructions for code)

Other (Specify) _______________________________________________________________________________________

25.

26.ALLEGED ERROR OR OMISSION (See instructions for code)

Other (Specify) _______________________________________________________________________________________

FORM PREPARED BY (PLEASE TYPE OR PRINT)

TELEPHONE NUMBER (AREA CODE) NUMBER, EXTENSION

 

 

SIGNATURE

DATE

4

MO 375-1662 (8-06)

LEGAL MALPRACTICE CLAIM REPORT INSTRUCTIONS

SECTION A Complete this section for all claims.

1.INSURER’S NAME - The full and legal name of the insurance company providing the coverage for this claim.

2.NAIC GROUP AND COMPANY CODE - Enter the NAIC four digit group code and the five digit company code for the company listed in Item 1.

3.INSURER CLAIM FILE NUMBER - Enter the company file number for this claim. Both alphabetic and numeric characters are permitted. DO NOT USE HYPHENS, DASHES, SLASHES OR SPACES.

4.INSURED’S CITY, STATE AND ZIP - Enter the city, state and zip code address for the insured against whom this claim was made. “State” is the two letter official postal code; i.e., MO, MA, KY, etc.

5.STATUS OF THIS CLAIM - Use A for each new claim opened and B for each of these new claims which are now closed. Use C if a claim is reopened and D for each of these reopened claims which are now closed.

6.STATE - The two letter official postal code of the state where the claim was made.

7.POPULATION CODE - Enter the two digit code for the city population where the claim was made.

8.thru 13. (Self-Explanatory)

14.DATE OF OCCURRENCE - This date and all other dates are to be reported in the form MM YY.

15.DATE FIRST REPORTED TO INSURER - Use the date format specified in Item 14.

SECTION B Complete this section for each closed claim only.

16.DATE THIS CLAIM CLOSED OR DISPOSED - Use the date format specified in Item 14.

17.CLAIM DISPOSITION - For this claim, enter the alpha code for FINAL method of disposition.

18.thru 22. Round all amounts to the nearest dollar.

SECTION C Complete this section for all claims.

23. AREA OF LAW - Enter the alpha code for which area of law the insured was retained by the client.

A.

Real Estate

N.

Civil Rights and Commission

B.

Estate, Trust & Probate

O.

Consumer Claims

C.

Family Law

P.

Construction (Building Contracts)

D.

Personal Injury/Property Damage-Plaintiff

Q.

Corporate and Business Organization

E.

Personal Injury/Property Damage-Defendant

R.

Environment

F.

Workers’ Compensation

S.

Government Contracts and Claims

G.

Securities (S.E.C.)

T.

Immigration and Naturalization

H.

Patents, Trademarks, Copyrights

U. International Law

I.

Collection and Bankruptcy

V. Labor Law

J.

Taxation

W. Local Government

K.

Criminal

X. National Resources

L.

Admiralty

Y. Business Transactions/Commercial Law

M.Antitrust

24.MAJOR ACTIVITY CODE - Indicate the one major activity which the licensee was engaged in at the time the alleged error occurred.

A.Commencement of action or proceeding (initial pleading, service)

B.Pre-trial, pre-hearing (investigation, subsequent pleading, discovery, motion)

C.Trial or hearing

D.Post trial or hearing

E.Appeal activities

F.Preparation, transmittal or filing of documents other than pleadings

G.Settlement and negotiation

H.Exparte (noncontested) proceedings, i.e., adoption and probate

I.Investigation, other than litigation

J.Tax reporting or payment

K.Title opinion

L.Other written opinion

M.Consultation or advice

N.Recommendation of or referral to another professional including another lawyer

O.Other (Please specify on front)

25.ALLEGED ERROR OR OMISSION - Indicate the one alleged error or omission which is the most significant to the cause of the claim being made.

A.

Failure to calendar properly

L.

Failure to understand or anticipate tax consequences

B.

Failure to react to calendar

M.

Failure to know or properly apply to law

C.

Failure to know or ascertain deadline correctly

N.

Failure to follow client’s instructions

D.

Failure to file documents where no deadline is involved

O.

Failure to obtain client’s consent or to inform client

E.

Procrastination in performance of services or lack of follow-up

P.

Improper withdrawal from representation

F.

Error in mathematical calculation

Q.

Conflict of interest

G.

Lost file, document or evidence

R.

Libel or slander

H.

Clerical error

S.

Malicious prosecution or abuse of process

I.

Error in public record search

T.

Violation of civil rights

J.

Planning or strategy error

U.

Fraud

K.

Inadequate discovery of facts or inadequate investigation

V.

Other (Please specify on front)

MO 375-1662 (8-06)

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2. Once your current task is complete, take the next step – fill out all of these fields - E After judgment or decision but, What amount was paid to the, What amount was paid for loss, What reserve amount was, What reserve amount was, What was the amount of the, SECTION C, AREA OF LAW See instructions for, MAJOR ACTIVITY CODE See, Other Specify, ALLEGED ERROR OR OMISSION See, Other Specify, FORM PREPARED BY PLEASE TYPE OR, TELEPHONE NUMBER AREA CODE NUMBER, and SIGNATURE with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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