ROBERT L. EHRLICH, JR., Governor

Ch. 5

(2) THE COMMISSIONER SHALL ADOPT REGULATIONS ON THE
SUBMISSION OF INFORMATION DESCRIBED IN PARAGRAPH (1) OF THIS SUBSECTION.

(B) IN ADDITION TO THE INFORMATION REQUIRED UNDER SUBSECTION (A)
OF THIS SECTION, EACH INSURER PROVIDING PROFESSIONAL LIABILITY INSURANCE
TO A HEALTH CARE PROVIDER IN THE STATE SHALL SUBMIT TO THE COMMISSIONER
THE FOLLOWING INFORMATION:

(1) (I)     NAME OF INSURER;

(II)    NAME OF INSURER GROUP;

(III)   CLAIM FILE IDENTIFICATION;

(IV)   NAME OF PERSON COMPLETING FORM;

(V)      TELEPHONE NUMBER (AREA CODE); AND

(V)    DATE FORM COMPLETED;

(2) (I)       DATE OF INJURY;

(ID    DATE INJURY REPORTED TO INSURER; AND

(III)   DATE CLAIM CLOSED;

(3) AGE OF INSURED PERSON AT TIME OF INJURY;

(4) WHETHER THE INJURED PERSON WAS EMPLOYED AT THE TIME OF
INJURY;

(5) (I) TYPE OF INJURY; AND

(II) DESCRIPTION OF INJURY;

(6) (I) TYPE OF MEDICAL PROFESSIONAL LIABILITY POLICY;

(II) HOSPITAL OR RELATED INSTITUTION CLASSIFICATION
EXPOSURE BY NUMBER OF BEDS;

(III) HOSPITAL OR RELATED INSTITUTION CLASSIFICATION
EXPOSURE BY NUMBER OF OUTPATIENTS;

(IV) WHETHER PATIENT WAS:

1. INPATIENT;

2.       EMERGENCY ROOM OUTPATIENT; OR

3.       OTHER OUTPATIENT;

(V) PHYSICIAN ISO CLASSIFICATION;

(VI)    OTHER HEALTH CARE PROVIDER, INCLUDING DENTAL ISO
CLASSIFICATION;

(VII)  HEALTH CARE PROVIDER NAME AND LICENSE NUMBER; AND

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