Get Sedgwick Workers Compensation Standard Intake Form 2013-2025

The Sedgwick Workers Compensation Standard Intake Form is an essential document for reporting workplace injuries and initiating claims. This guide will provide clear, step-by-step instructions on how to complete the form online, ensuring a smooth and efficient process for all users.

Follow the steps to complete your intake form online

1. Press the ‘Get Form’ button to access the intake form and open it in your digital interface.
2. Begin by entering the client name and contract number at the top of the form.
3. Provide the reporter information, including first name, last name, title, phone number, and extension.
4. Fill in the location information. Enter details such as unit name, street address, city, phone number, state, and zip code. Indicate whether this is the loss location.
5. If the loss location is different, fill in the corresponding fields for loss location information.
6. For claimant information, input the employee ID number, home phone, home address, email address, date of birth, and full name.
7. Complete the claimant employment information section, including employee title, work status, wage amount, and hours worked per day.
8. Provide the claimant supervisor information, including their first name, last name, title, phone number, email address, and check the question related to the validity of the claim.
9. Document incident information by detailing the date and time of the incident, department, description of the incident, and whether safeguards or safety equipment were provided.
10. Fill in the medical information if treatment was received, including facility name, physician name, and transportation type.
11. Input any witness information, including their name and contact details.
12. In the lost time information section, indicate if the claimant will miss work, the last date worked, and if salary will continue.
13. Finally, review all entered information for accuracy. Save your changes, and utilize the options to download, print, or share the form as needed.

Complete your Sedgwick Workers Compensation Standard Intake Form online today for a seamless filing experience.