CLAIMS

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Owner/Operator Services, Inc. Texas Non-subscriber Employee Injury Only

*Required




Please Answer the Following Questions
Was medical treatment required?*
Did the employee go to a company approved physician?*
***If you answered "no", this claim will be used for record only. Please complete the rest of this form as well as the Employee Report, Supervisor Report, and the Witness Statement and keep for your records. If the employee's condition changes and medical treatment is needed please call Owner/Operator Services so we can file your claim.
Did the employee miss any work?*
Refer to the 3 step process employee injury claim book for all necessary forms.
Has the Employee Accident Report been completed?*
Has the Supervisor's Report of the Accident been completed?*
Has the Witness Statement(s) been completed?*
If medical treatment is required, injured employee must take with them the following documents:

Please send all claim forms to:
Sedgwick - Attn: Chuck Eastwood
charles.eastwood@sedgwickcms.com
Fax: 210-332-1590
Direct: 210-332-1611 or 800-800-3795 x-21611
Mailing Address: P.O. Box 14499, Lexington, KY 40512-4499