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.

   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.**

    **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