K&B SENIOR LIVING PROGRAM CONFIDENTIAL INITIAL CLAIM REPORT FORM
(1) Resident or Claimant Name:
Date of Birth:
Social Security #:
Gender: / (2) Date of Occurrence:
(3) Insured Name:
Insured Address:
Insured Contact/Phone: / (4) Broker Name/Address/Phone:
Policy Number:
Effective Dates:
Retro Date:
Limits:
(5) Resident or Claimant Address (City,State,Zip) /
Phone:
Claimant Type:Resident ______Visitor:______Other:______
Witnesses:
Claimant/Plaintiff Attorney:
Address/Phone:
Claim Status Information:
(6) Recovery Potential: ____Yes ____No
(7) Status: ___Incident ___Claim ___NOI ___Suit
(8) Sentinel Event: ___Yes ___No
(9)Incident Report Date: ___/___/___ (if applicable) / (10) Claim Date:___/___/___
(11) Suit Filed Date (if known): ___/___/___
(12) Suit Received Date:___/___/___
(13) Event Description:
(14) Remarks:
Defense Counsel Info.:
(15) Legal Firm: / (16) Attorney Assigned:
(17)Person Completing Form: / (18) Date:
Confidential Report to Attorney Not a Part of the Medical Record
HOW TO REPORT:Submit this form via email to:
Mail or fax additional information to Yvonne Stamper, phone (713) 914 -3242/fax (713) 914- 3250,
address listed below:
Sedgwick CMS PL-MCU
P.O. Box 14478
Lexington, KY 40512
INSTRUCTIONS FOR COMPLETING THE CLAIMS INITIAL REPORT FORM
1.Claimant Name - First and last name of the injured or damaged party.
2.Occurrence Date - The date the occurrence or incident occurred.
3.Insured Name- Facility involved
4.Policy Information - Self-explanatory.
5.Claimant Information - All information in this section relates to the claimant/injured party.
6.Recovery Potential - Any professional or general liability claim in which it appears another party could be held legally liable for the incident or occurrence.
7.Indicate if the current Status is an incident, claim, NOI or suit.
8.Sentinel Event – Yes or No
9.Incident Report Date - If an incident report was filed, indicate the date the incident report was completed.
10.Claim Date - Indicate the date you became aware that the claimant intended to pursue a claim.
11.Suit Filed Date - Complete if known. Is generally noted on the top of the complaint.
12.Suit Received Date - The date the facility was served.
13.EventDescription - A brief, concise, and objective description of the event or occurrence.
14.Remarks - Remarks or comments the Sedgwick Claims staff should be made aware of regarding the event.
15.Legal Firm - This refers to the law firm that you would recommend in the event the case is likely to end up in litigation or litigation has already been initiated. Do not complete if it appears obvious that the case will not be litigated or if you are relying on Sedgwick to recommend counsel.
16.Attorney Assigned - If #16 applies, indicate if you have a preference. If not, Sedgwick will assign from current defense panel.
17.Person Completing Form - Signature of the person completing the Initial Report Form.
18.Date - This is the date the Initial Report Form has been completed and will serve as the date on which Sedgwick was notified.
Confidential Report to Attorney Not a Part of the Medical Record