Ebilling implementation request form

Guidelines

By completing this form, vendor agrees:

To submit all invoices through 港澳图库's e-billing system.
All invoices are subject to review by 港澳图库.
To abide by all 港澳图库 litigation management and billing standards.

All fields are required unless otherwise noted.
If a field is not applicable please use N/A.
List all current 港澳图库 matters being handled by your firm.
If you have issues submitting this form, please contact mattersetup@markel.com.

Fields with an asterisk (*) are required.

Vendor information

Name (firm or company):

TIN:

Address

City:

State:

Zip/Postal code:

Country

Billing contact phone:

Billing contact fax:

Billing contact first name:

Billing contact last name:

Billing contact e-mail:

Billing contact title:

Attorney contact first name:

Attorney contact last name:

Attorney contact title:

Attorney contact e-mail:

Attorney contact phone:

Your firm鈥檚 liability (errors & omissions) insurance

E&O carrier name:

E&O limits of liability:

E&O policy effective date:

E&O policy expiration date:

E&O SIR/deductible:

Current matter assignments

Matter assigned date:

港澳图库 claim number:

Name of examiner:

Name of insured:

Name of claimant:

Litigation type:

Check here to list additional 港澳图库 matters being handled by your firm.

Matter 2 assigned date:

港澳图库 claim number:

Name of examiner:

Name of insured:

Name of claimant:

Litigation type:

Matter 3 assigned date:

港澳图库 claim number:

Name of examiner:

Name of insured:

Name of claimant:

Litigation type:

Matter 4 assigned date:

港澳图库 claim number:

Name of examiner:

Name of insured:

Name of claimant:

Litigation type:

Matter 5 assigned date:

港澳图库 claim number:

Name of examiner:

Name of insured:

Name of claimant:

Litigation type:

Check here if more than 5 港澳图库 matters are being handled by your firm.

港澳图库

Suggested