Specific Notice of Loss

Effective

Policy effective date.

Policyholder

Policy holder name.

Employee

Employee with a relationship to the claimant.

Claimant

Claimant name.

Age

Claimant age.

Diagnosis

Medical diagnosis precipitating the claim.

Date of Onset

Date when the medical condition first began.

LCM

Loss Cost Multiplier.

Total Reported

Total loss reported.

Specific Deductible

Deductible amount for the policy's specific coverage.

Date Received

When the loss was reported.