Claim Reporting Form (all fields must be completed)
Print Claim Form
Name
Address
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Guam
Northern Mariana Islands
Puerto Rico
United States Virgin Islands
Zip Code
Cell Phone
SSN (Last Four Digits)
FOP ID Number
FOP Lodge Number
FOP Lodge Name
FOP State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Guam
Northern Mariana Islands
Puerto Rico
United States Virgin Islands
Date Alleged
Conduct Took Place
Please provide
personal e-mail
Claim Type(s) check all that apply
Administrative
Criminal
Salary Reimbursement Option
Civil
Civil Monitoring
Retired Law Enforcement Concealed Carry Legal Defense Coverage (CCC)
Select one:
On-duty
Off-duty
Description of the incident leading up to the claim presented
*(E-mail a separate sheet if necessary)
Has a lawsuit been filed (civil)?
Yes
No
*(If yes, please e-mail a copy of the suit)
Have you contacted an attorney?
Yes
No
Attorney Information
Firm/Business Name
Attorney Name
Address
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Guam
Northern Mariana Islands
Puerto Rico
United States Virgin Islands
Zip Code
Phone
Fax
E-mail
Assistant Name
Assistant E-mail
Signature
Date Signed
*If you are unable to submit your completed claim form due to a Signed Date error, please try entering the date for the following day.
*Please e-mail any letters, notices or other documents you have that are connected to your claim to
foplegal@sedgwick.com
. This will allow us to quickly determine if coverage applies.