Claims Intake Form In case of emergency please call (800) 258-1036. "*" indicates required fields Δ Client InformationEmployer Name* First Client/Employer Name*State/Region*Client Contact Name*Contact Phone Number*Contact Email* Employee InformationEmployee's Name (REQUIRED)* First and Last Employee's Email (REQUIRED)* Employee's Phone Number (REQUIRED)*Employee's Address (REQUIRED)* Street Address Employee's SSN (REQUIRED)*Employee's Date of Birth (REQUIRED)* MM slash DD slash YYYY Accident InformationDate of Injury (REQUIRED)* MM slash DD slash YYYY Type of Injury [Fall, Strain, Sprain, Etc.] (REQUIRED)*Body Part(s) Injured (REQUIRED)*Brief description of the incident (REQUIRED)*Accident Site Full Address (REQUIRED)* Street Address Treatment Requested? [If so, provide name/address/phone number below]* Yes No We are committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and provide the products and services you have requested from us. If you consent to us contacting you for this purpose, please check below:* I agree to receive communications from KRUSE.You may unsubscribe from these communications at any time. Please review our Privacy Policy. By clicking submit below, you consent to allow Kruse to store and process the personal information submitted above to provide you the service requested.NameThis field is for validation purposes and should be left unchanged.
