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 (Non-Plan attorney selection results in $250 deductible due by member)
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.