Get Sedgwick Auto Liability Intake Form

The Sedgwick Auto Liability Intake Form is an essential document for reporting incidents involving auto liability claims. This guide will walk you through the process of filling out the form online, ensuring that you provide all necessary information clearly and accurately.

Follow the steps to complete the Sedgwick Auto Liability Intake Form online.

1. Press the ‘Get Form’ button to obtain the Sedgwick Auto Liability Intake Form and open it in your preferred editor.
2. Begin by entering the Client Name and Contract Number at the top of the form, ensuring accuracy as this information is crucial.
3. In the Reporter Information section, fill in the First Name, Last Name, Title, Phone number, and Extension if applicable.
4. For Client Location Information, provide the Location Number, Location Name, Street Address, City, State, Zip Code, Phone number, and Extension.
5. Indicate whether the provided location is the loss location by checking either 'Yes' or 'No'.
6. Complete the Incident Information section by entering the Date of Incident, Time of Incident (select AM or PM), Date Employer Notified, and a detailed Incident Description. Also, fill in the Road Conditions, Weather Conditions, Speed Limit, and whether the Driver was Wearing a Seatbelt or using a Cell Phone.
7. If the incident location differs from the Client Location, complete the Incident Location Information, including Name, Street Address, City, State, Zip Code.
8. In the Authority Information section, provide the Authority Name, Phone number, Extension, Authority Report Number, and Officer Name.
9. Fill in the Insured Driver Information accurately. This includes Employee ID, SSN, First Name, Middle Initial, Last Name, Home Phone, Work Phone, and Extension. Include their Home Address, City, State, Zip Code, Date of Birth, Marital Status, Gender, Driver's License Number, State, and whether a Citation was Issued.
10. Document any Injury Information by providing a Description of Injury, Cause, Body Part, and Nature of the Injury.
11. For Medical Treatment Information, indicate if the person was Admitted to Hospital, provide Facility Name, Street Address, City, State, Zip Code, Phone number, Extension, and Transportation Type.
12. Input the Insured Vehicle Information, including Vehicle Fleet Number, VIN, Body Type, Year, Model, Color, License Plate Number, State, Damage Description, Estimated Damage, and whether it was Towed.
13. If applicable, provide details about the Other Driver Information in the same manner as the Insured Driver Information.
14. In the Damaged Property Information section, describe the damaged property, Damage Description, and Estimated Damage.
15. Complete the Other Insurance Information if relevant by providing the Carrier Name and Phone Number.
16. Fill out the Injured Party Information section, providing First Name, Middle Initial, Last Name, Home Phone, Work Phone, and address details.
17. Conclude with any Witness Information, filling out Name, Address, City, State, Zip Code, and Phone Number.
18. Finally, review all fields for accuracy, make any necessary edits, and save changes. You can then download, print, or share the completed form as appropriate.

Start completing your Sedgwick Auto Liability Intake Form online today!