Claim/Incident Report

2. YOU DO NOT NEED TO SIGN-IN TO COMPLETE THIS FORM
4. USE THIS FORM FOR REPORTING ALL CLAIMS OR INCIDENTS TO CCOB RISK MANAGEMENT
   If you have knowledge or have received information about a potential claim, please complete the following report as soon as possible. It is very important that the incident is reported timely with whatever information you have so that a claim file can be created, an investigation can be completed, and our insurance representatives can be notified.
6. Please note, additional information can be sent to riskmanagement@broomfield.org as it becomes available.
8. INFORMATION OF PERSON COMPLETING THIS REPORT
10. First Name*
11. Last Name*
13. Email*
14. Phone Number*
16. Address1
18. Address2
20. City
21. State
22. Zip
26. INCIDENT INFORMATION
28. Type of Incident*
    -- Select One --Auto AccidentProperty DamageBodily InjuryOther
29. Date of Incident*
    Date of Incident
30. Time of Incident
    Time of Incident
32. Name of Claimant or Other Party (If minor, name of parent)*
34. Claimant's Phone Number
35. Claimant's Email Address
37. Address/Location of the Incident*
39. Description of the Incident (Include all known information)*
41. Were Broomfield Employees Involved?*

    1. Yes

    1. No
42. If yes, please list their name(s)
46. ADDITIONAL INFORMATION (IF APPLICABLE)
48. Name & Phone Number of Witnesses
50. Accident or Police Report Number
51. Unit Number
53. Date Reported to Supervisor & Supervisor's Name
55. Additional Information
    Please include claimant's insurance information, how the accident could have been prevented, or any additional information not provided in the description of the incident.
59. PLEASE ATTACH ANY APPLICABLE DOCUMENTS
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78. SUBMIT/SIGN
80. PLEASE ENTER YOUR LEGAL NAME AS AN ELECTRONIC SIGNATURE*
    By typing in your name here, you are signing this document.
81. Date*
83. Risk Management will review and respond within 24 hours. If you have any questions, please contact the Risk Management Division at riskmanagement@broomfield.org or 303-438-6231.
    **Please call Fleet Services at 303-438-6336 or email Public Works at publicworks@broomfield.org if a City/County vehicle is damaged and needs repair.**
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85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field