Claim Reporting Form (all fields must be completed)
Name
Address
City
State
Zip Code
Work Phone
Home Phone
Cell Phone
SSN (Last Four Digits)
FOP ID Number
FOP Lodge Number
FOP State
Date Alleged
Conduct Took Place
Click here to choose a date.
Please provide
personal e-mail
Claim Type(s) check all that apply
Civil (excess) Civil Monitoring Civil - on-duty
Criminal Criminal - on-duty Salary Reimbursement Option
Administrative - on-duty Administrative - off-duty HR-218 (LEOSA)
Description of the incident leading up to the claim presented
*(E-mail a separate sheet if necessary)
Has a lawsuit been filed (civil)? *(If yes, please e-mail a copy of the suit)
Have you contacted an attorney?
Attorney Information (Non-Plan attorney selection results in $250 deductible due by member)
Firm/Business Name
Attorney Name
Address
City
State
Zip Code
Phone
Fax
E-mail
Assistant Name
Assistant E-mail
Signature Date Signed Click here to choose a date.
*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.