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Claim/Incident Report

  1. YOU DO NOT NEED TO SIGN-IN TO COMPLETE THIS FORM

  2. 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.

  3. Please note, additional information can be sent to riskmanagement@broomfield.org as it becomes available.

  4. INFORMATION OF PERSON COMPLETING THIS REPORT

  5. INCIDENT INFORMATION

  6. Were Broomfield Employees Involved?*

  7. ADDITIONAL INFORMATION (IF APPLICABLE)

  8. 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.

  9. PLEASE ATTACH ANY APPLICABLE DOCUMENTS

  10. SUBMIT/SIGN

  11. By typing in your name here, you are signing this document.

  12. 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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  14. This field is not part of the form submission.