Fillable Sedgwick General Liability Intake Form (USDA Food and Nutrition Service)

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Sedgwick General Liability Intake Form (USDA Food and Nutrition Service)

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The Sedgwick General Liability Intake Form (USDA Food and Nutrition Service) form is 2 pages long and contains:

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  • 72 other fields

Country of origin: US
File type: PDF

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Sedgwick General Liability Intake Form
Use only for reporting AMXL claims (In-home delivery)
Please complete the information on screen and save to your computer
Email completed form to: DeliveryServiceProviders@sedgwickcms.com
Questions: 844-855-3765
Available 24 hours per day, 7 days per week
*Indicates a mandatory field that must be completed in order to accept a claim. However, in order to best process your request, please
provide as much information as possible.
*Insured Name:
Client Name: Delivery Service Providers
Contract Number: 6887
*DSP Station Code Where Vehicle Operates:
Reporter Information
*First Name:
*Last Name:
Title:
*Phone:
Email Address:
Primary Office Information
Street Address:
City:
State:
Phone:
Ext:
Insured Driver Information
First Name:
MI:
Home Phone:
Work Phone:
Home Address:
City:
State:
Zip Code:
Date of Birth:
Insured Vehicle Information
VIN:
Body Type:
Year:
Model:
Color:
License Plate Number:
State:
Incident Information
*Date of Incident:
*Time of Incident:
AM
PM
*Date Employer Notified:
*Incident Description (please attach separate page if necessary):
Incident Location Information
Street Address:
City:
State:
Homeowner Information (Customer)
First Name:
MI:
Home Phone:
Work Phone:
Home Address:
City:
State:
Other Party Injury Information
Description of Injury:
Was the other party transported by ambulance? Yes No
Sedgwick General Liability Intake Form
Use only for reporting AMXL claims (In-home delivery)
Please complete the information on screen and save to your computer
Email completed form to: DeliveryServiceProviders@sedgwickcms.com
Questions: 844-855-3765
Available 24 hours per day, 7 days per week
Damaged Property Information
Describe Property:
Damage Description:
Estimated Damage:
Witness Information
Name:
Address:
City:
State:
Zip Code:
Phone:
Contact Information
*First Name:
MI:
*Last Name:
*Phone:
Ext:
Email Address:
Comments/Remarks:
X-13858-919
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Sedgwick General Liability Intake Form (USDA Food and Nutrition Service)

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Completed 29 September 2020

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