NEW CLAIM FORM
Please complete the following for any new claim. If you have any questions, please contact Michelle Lynn Bock at Sedgwick CMS at 800-486-2152. This form may then be emailed or faxed to her attention at mbock@sedgwickcms.com or 402-291-0172. CLAIMANT INFORMATION (If there are multiple parties involved, please list them individually.): Name: Address: Phone Number: INSURED INFORMATION: Name: Address: Phone Number: Contact: DESCRIPTION OF INCIDENT (please include a brief description of the incident):
TYPE OF DAMAGES: Injuries: yes/no If yes, list injured: Property: vehicle/other property If other property, list property: LOSS DATE:
DATE INSURED WAS AWARE OF INCIDENT: