Reporting of judgments and settlements in accordance with 27-26-5, Code of Alabama 1975

* indicates a required field

Address of physician involved in action:



Judgment FOR physician
Judgment AGAINST physician
Settlement in OR out of court

Judgment

Settlement


# - Do not include the cost of defense in this amount and if the "insured" is other than an individual physician, please indicate the amount charged against the physician on whom this report is submitted


Provide the company name (or entity), name of individual, address, phone number and email address for the individual submitting the report.


 

This form uses Huggins' Email Form Script

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