Claim Loss History and Coverage Verification Request

Client Request

Coverys provides loss histories and coverage verification for healthcare providers who are insured with us now or were in the past. Please complete the form below to make a request. Requests are processed in the order they are received.

By checking here, I acknowledge that:
Coverys has taken reasonable steps to ensure that the information contained on claim loss history reports is accurate.
On occasion there may be an error or omission due to the high volume of data involved. Verification of the content by the provider is recommended before action is taken upon the information by the recipient.

A $30 fee is charged for each CLH report processed for non-Coverys policyholders and credentialing companies. We will mail an invoice to the requestor (please do not send prepayment).

Who is making the request?

First Name *

Middle Initial *

Middle Initial N/A

Last Name *

Former Name

Title *

Additional Information

Requestor Name *

Email *

At Least Two Required

Address 1*

Address 2

Address 3

City*

State*

Postal Code*

Claim years requested*

Since Inception

Or Select number of years below

Delivery Method *

Check this box if delivery address is the same as requestor address.

Address *

Address 2

Address 3

City *

State *

Postal Code *

Doctors

Organizations

Advanced Practice Providers

Insurance Types

Claim Loss History and Coverage Verification Request

Client Request