Criminal Defense Claim Form

Name(Required)

First Last

Employee Number(Required)

Email(Required)

Date of Incident

Has a lawsuit been filed against you?

Yes

Describe Incident Details Leading up to Claim

List Any Charges Filed or Discipline Received

Attach any 49’s, supplemental reports, memos or correspondence from the Department concerning your case

Max. file size: 100 MB.

Comments

This field is for validation purposes and should be left unchanged.

When Choice, Control & Credibility Matter