Preliminary notification of a possible specific Stop/Loss claim - a claim has reached 50% of the specific deductible
	Large Claim Management Referral - When the potential for a large claim exists because of the diagnosis or injury

Insurance Carrier:
Employer's Name:
Policy Number & Type:

Employee Name:		Date of Birth:		SSN:
Patient's Name:		Date of Birth:	Relationship to Employee:

CONDITION DETAILS:

PRIMARY TREATING PHYSICIAN: Name: Address & Telephone Number: Primary Diagnosis: CD-9 Code: Date of Onset:

DESCRIBE ANY COMPLICATIONS & LIST MAJOR SURGICAL PROCEDURES

CURRENT MEDICAL STATUS (eg hospital confined, paralyzed, comatose, returned to work, etc):

IF CONFINED: Name of Facility: Address & Telephone Number: Admit Date: Actual or Estimated Date of Discharge:

PROGNOSIS: (MUST BE COMPLETED): Estimate of Future Potential Liability:   (MUST BE COMPLETED) TOTAL AMOUNT OF CLAIMS: Paid to Date: Amount Pending:

COVERAGE:

Employee's Date of Hire:	Employee's Effective Date Under Employer's Plan:	Dependent's Effective Date if Applicable:
Policy Period: From: To:	Specific Deductible: Aggregate Deductible:

Is Employee or Dependent Coverage still in force? Yes No If NO, termination date:  Has Pre-existing been investigated? Yes No   Has subrogation been investigated? Yes No   Is coverage under this Employer plan? Primary Secondary   Is Case Management being utilized? Yes No

List any other limitation & exclusion applicable to this claim:

RESERVATION OF RIGHTS: The Company has not determined if the expenses incurred by the patient are covered under Stop Loss Policy & completion of this form will not affect that determination. Administration of this claim under the Large Claim Management Program does not mean the Company has waived its right to investigate the claim. All terms and conditions of the Stop Loss policy will apply to this claim unless specifically waived.

TPA Name: Telephone: Completed By: Date Completed: E-Mail: