Sedgwick Reporting Form- General Liability

• Date and Time

  Date

• Prepared By

Incident Qualification

• Date and Time of Incident

  Date

• Date and Time Operator was notified

  Date

Restaurant Location Information

• Unit #

• Unit Name

• Unit Phone #

• Address

• City

• State

• Zip Code

• Name of individual reporting incident

• Title

• Phone #

Incident Information

• Incident Details

Witness Information

• Name

• Phone #

• Name

• Phone #

• Name

• Phone #

Authorities

• Authority Contacted

• Reference #

• Contact Name

• Contact Phone #

• Ext.

Claimant Information

• First Name

• Middle Initial

• Last Name

• Home Phone #

• Work Phone #

• Address

• City

• State

• Zip Code

• Date of Birth

  Date

• Male or Female

  Male

  Female

• Marital Status

  Select Single Married Divorced Seperated Widowed Unknown

  • Single
  • Married
  • Divorced
  • Seperated
  • Widowed
  • Unknown

• Relationship to Client

  Select Employee Spouse Self Customer Unknown Other

  • Employee
  • Spouse
  • Self
  • Customer
  • Unknown
  • Other

• Injury Cause

• Body Part

• Nature of Injury

• Claimant's Employer

• Occupation

Medical Provider

• Doctor's Name

• Address

• City

• State

• Zip

• Hospital/Clinic Name

• Transportation to Medical Provider

  Select 3rd Party Drove Self Ambulance Air Lifted Unknown Other

  • 3rd Party
  • Drove Self
  • Ambulance
  • Air Lifted
  • Unknown
  • Other

Claimant Information (2)

• First Name

• Middle Initial

• Last Name

• Home Phone #

• Work Phone #

• Address

• City

• State

• Zip Code

• Date of Birth

  Date

• Male or Female

  Male

  Female

• Marital Status

  Select Single Married Divorced Seperated Widowed Unknown

  • Single
  • Married
  • Divorced
  • Seperated
  • Widowed
  • Unknown

• Relationship to Client

  Select Employee Spouse Self Customer Unknown Other

  • Employee
  • Spouse
  • Self
  • Customer
  • Unknown
  • Other

• Injury Cause

• Body Part

• Nature of Injury

• Claimant's Employer

• Occupation

Medical Provider (2)

• Doctor's Name

• Address

• City

• State

• Zip

• Hospital/Clinic Name

• Transportation to Medical Provider

  Select 3rd Party Drove Self Ambulance Air Lifted Unknown Other

  • 3rd Party
  • Drove Self
  • Ambulance
  • Air Lifted
  • Unknown
  • Other

Property Damage

• Describe Item

• Damage Description

• Insurance Provider

• Policy #

• Where can property be seen?

• Address

• City

• State

• Zip Code

• Time

  Date

Supplement Questions

• Where in the restaurant was the claimant injured?

Additional Comments

• Comments

Media

• Picture1

  Media

• Picture 2

  Media