Attachment B

Record of Civil Actions/Malpractice Claims

Name
First Middle Initial Last
Email*
Complete Title of Action
Court File Number
Date(s) the claim/action was filed
Name and complete address of court or entity with possession of documents:
Name of Court Address City, State, ZIP Code Telephone Number
Name and complete address of professional liability company (if applicable):
Name Address City, State, ZIP Code Telephone Number
Plaintiff Information
Name Address City, State, ZIP Code Telephone Number
Plaintiff's Attorney Information
Name Address City, State, ZIP Code Telephone Number
Defendant Information
Name Address City, State, ZIP Code Telephone Number
Defendant's Attorney Information
Name Address City, State, ZIP Code Telephone Number
Trial Date
MM
DD
YYYY
Date of Final Disposition
Date Format: MM slash DD slash YYYY
Disposition
Narrative summary of the civil action/claim including a description of all alleged causes of action and defenses raised: (For Bankruptcy proceedings, please provide a description of the circumstances leading up to and surrounding the filing of any such proceeding)
If the disposition resulted in a judgment, has the judgment been satisfied?
- Yes
- No
If yes, give the date the judgment was satisfied and attach evidence of the same:
If no, what amount is still owing and why:
Attach copies of all evidence including: pleadings, petitions, schedules, discharges, objections to discharge, adversary proceedings, judgments and/or final orders.
Drop files here or