CLAIMS Quick LinksSubmit Claim Online Claim Forms Claim Reporting Procedure Reimbursement Procedure Submit Claim Report Online Owner/Operator Services, Inc. Texas Non-subscriber Employee Injury Only *Required Please Answer the Following Questions Was medical treatment required?* ---YesNo*** Did the employee go to a company approved physician?* ---YesNoN/A ***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?* ---YesNo Refer to the 3 step process employee injury claim book for all necessary forms. Has the Employee Accident Report been completed?* ---YesNot Yet Has the Supervisor's Report of the Accident been completed?* ---YesNot Yet Has the Witness Statement(s) been completed?* ---YesNot YetNo Witnesses If medical treatment is required, injured employee must take with them the following documents: Authorization for Initial Treatment (completed & signed by the manager) Release of Medical Records (signed by injured employee) No Cost to operator or injured employee: Prescription First Fill Form (completed by the manager) Physicians Report of Employee Injury (to be complete by the approved provider) Please send all claim forms to: Sedgwick - Attn: Chuck Eastwood firstname.lastname@example.org Fax: 210-332-1590 Direct: 210-332-1611 or 800-800-3795 x-21611 Mailing Address: P.O. Box 14499, Lexington, KY 40512-4499 Please leave this field empty.