MagMutual Insurance Company

Confidential attorney work product in anticipation of litigation or claim, subject to peer review privilege.

***This form contains protected health information which must be protected and safeguarded. This form may only be transmitted by a secure, encrypted email system. If you do not have a secure, encrypted email system, DO NOT email this form to MagMutual. You may call the Claims Department at 1-800-586-6891.***

If you are reporting a workers’ compensation incident, please report via service.magmutual.com or email the First Report of Injury to alliedlinesclaims@magmutual.com.
PolicyOwner Information
Name*
First Last
Employer*
Address*
Street Address City State ZIP Code
Phone Numbers*
Phone Number * Secondary Number
Email*
Person Submitting Report
Name*
First Last
Phone Numbers*
Phone Number * Secondary Number
Email*
Policy Number
Effective Dates
Date Matter Reported*
MM
DD
YYYY
Date Matter Occurred*
MM
DD
YYYY
Type of Matter*
- Lawsuit
- Notice of Intent
- Claim (demand for payment)
- Deposition Request
- Medical Board Investigation or Proceeding
- Regulatory Investigation or Proceeding
- Billing Audit
- Privacy or Information Security Incident
- Employment-related Matter
- Property Damage
- Fall or Injury on Property
- Evacuation
- Incident/Precautionary/Other (please provide details below)
Date Received*
MM
DD
YYYY
Patient Information
Name*
First Last
Email Address*
Phone Number*
Address*
Street Address City State ZIP Code
Date of Birth
MM
DD
YYYY
Gender*
Please describe what happened.*

Mid-Atlantic Women’s Care consists of over 30 OB/GYN facilities and 5 Imaging Centers throughout the Hampton Roads community

Corporate Office
757-455-8833

Corporate Office
6353 Center Drive, Suite 100
Norfolk, Virginia 23502

Phone Number *	Secondary Number

Phone Number *	Secondary Number

PolicyOwner Information