Nov, 19, 2010 3:42PM DBIC No,5025 P, 2

Oregon NegligencelMalpractice Claim Report Farnl

Oregon Board of Dentistry 1600 SW 4th Avenue, Suite 770 • Portland, Oregon 97201

(971) 673-3200' www.oregon,govlDentistry

re ort1n ent! . Please send the rinted, com leled form to the Ore on Board of Dentis at the address above,

Insurer Name: Dentists Benefits Insurance Company

Injured person's name: Thomas Elliott

Allegations Bnd reasons for claim. State patient's actual, origInal, abnormal condition and llDy materLaI diagnosis, procedure, planning error, medicallnJur or other aJleglltion: (Attach a copy 0 the complaint to this sheet)

Pallenfs inner right cheek waS burned by a dental hand piece that malfunctioned when the water stopped runnrng thru It during

drilling. The burn Is minor and required 1 MD visIt.

1/1 8/2008

Per ORS 742.400 (4), ".,.&I1Y insurer required to report to a board under this section shall also be required to advise the appropriate licensing board of any settlements. awards or judgments against a physician. optometrist, dentist or dental hygienist or naturopath within 30 days ufter the date of the settlement, award or judgment... " The form below should be completed for every claim received by the