ROBERT L. EHRLICH, JR., Governor                               H.B. 2

5.       JUDGMENT FOR THE PLAINTIFF;

6.       JUDGMENT FOR THE DEFENDANT;

7.       FOR PLAINTIFF, AFTER APPEAL;

8. FOR DEFENDANT, AFTER APPEAL; OR

9. ANY OTHER;

(III) IF THERE WAS NO FINAL JUDGMENT OR SETTLEMENT, THE
DATE AND REASON FOR THE FINAL DISPOSITION; AND

(IV) IF CASE DID GO TO TRIAL, WHETHER THE CASE TRIED BY A
JURY;

(10)    (I) WHETHER THERE WERE DEFENDANTS OTHER THAN THE
INSURED INCLUDED IN THE ORIGINAL CLAIM OR AN AMENDED VERSION OF THE
CLAIM AND, IF SO, HOW MANY OTHER DEFENDANTS THERE WERE AND WHETHER
THE OTHER DEFENDANTS WERE:

1. PHYSICIANS OR SURGEONS; OR

2. HOSPITALS OR OTHER HEALTH CARE PROVIDERS;

(II) IF A PHYSICIAN OR SURGEON WAS A DEFENDANT, THE
DEFENDANT'S NAME AND LICENSE NUMBER; AND

(III) IF A HOSPITAL OR OTHER HEALTH CARE PROVIDER WAS A
DEFENDANT, THE DEFENDANT'S NAME AND LICENSE NUMBER;

(11)    (I) IF CASE WAS TRIED TO VERDICT, AND IF APPLICABLE, THE
PERCENTAGE OF FAULT ASSIGNED TO YOUR INSURED;

(II)     IF CLAIM WAS SETTLED, AND IF APPLICABLE, AN ESTIMATE OF
THE PERCENTAGE OF FAULT FOR THE INSURED; AND

(III)    THE PERCENTAGE OF THE FINAL AWARD OR SETTLEMENT
PAID BY THE INSURER;

(12)    WITH RESPECT TO THE TOTAL AMOUNT PAID TO THE CLAIMANT:

(I) THE AMOUNT PAID BY THE INSURER;

(II) THE AMOUNT PAID BY THE INSURED DUE TO RETENTION OR
DEDUCTIBLE;

(III) THE AMOUNT PAID BY AN EXCESS CARRIER;

(IV) THE AMOUNT PAID BY THE INSURED DUE TO SETTLEMENT OR
AWARD IN EXCESS OF POLICY LIMITS;

(V) THE AMOUNT PAID BY OTHER DEFENDANTS OR
CONTRIBUTORS; AND

- 159 -