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Get 400 SW 8th Street, Suite C, Des Moines, IA 50309-4686

Suit you have been named a party. Summaries of this information from insurance carriers is not acceptable. Submit the requested documentation for each suit. You do not need to submit this form if you have not been named in a professional liability suit. Name of patient/plaintiff: Date of event: Date of suit: Does the suit involve any of the following? Yes No Death of the patient Wrong sided surgery Loss of limb or major organ What is/was your role in the suit or claim: Primary defendant Co-d.

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