Internal Claim/Incident Reporting Form

Incident/Claim Information

Incident Type

Incident Date

Incident Time

Format Example 6:45 am or 12:36pm

Department / Division / Program

Type Department name to start the lookup

Department ID

Police Report Number

Incident Address

Incident City

Incident State/Province

Incident Country

Incident / Hazard Description

Vehicle / Equipment / Trailer Involved?

Property Damage to Others?

Estimated Damages/Losses ($)

Please insert dollar amount only.

Reported By

Form Was Completed By Employee Name (Lookup)

Type name to start the lookup

Form Was Completed By Employee Name ID

Form Was Completed By Employee Email

Involved Person Details

"Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include the claimant, employee, witness to the Incident, lawyer, property manager, etc.)

Involvement Type

Employee Name (Lookup)

Type name to start the lookup

Claimant Employee Name ID

First Name

Last Name

If unknown please type UNK

Phone

Birthdate

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

This Form Was Completed By

Description of Personal Injuries (If Applicable) / Description of Involvement

Seek Medical Attention?

Care from Emergency Medical Services?

Health care provider's name

Do you wish to add another Involved Persons?

Involved Person Details

Involvement Type

Employee Name (Lookup)

Type name to start the lookup

Additional Employee Name ID

First Name

Last Name

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Call Phone Number from Ambulance Call Report

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

Description of Personal Injuries / Description of Involvement

Seek Medical Attention?

Care from Emergency Medical Services?

Health care provider's name

Involved Vehicle / Equipment / Trailer

City of Loveland Vehicle or 3rd Party Vehicle

Vehicle Unit #

Vehicle Make

If make not known, please insert "N/A"

Vehicle Model

Vehicle License Plate Number

Vehicle Year

Vehicle Type

Description of Damages

Would you like to add another Vehicle?

Involved Vehicle / Equipment / Trailer 2

City of Loveland Vehicle or 3rd Party Vehicle

Vehicle Unit #

Vehicle Make

If make not known, please insert "N/A"

Vehicle Model

Vehicle License Plate Number

Vehicle Year

Vehicle Type

Description of Damages

Involved Property (Non-Auto)

City of Loveland Property or 3rd Party Property

Property Address

Description of Damages

To add another property, please select "Add another response" on the bottom-right portion of this section.

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages.

File Upload

To add more than one attachment, select "Add Another Response". To remove the additional file upload option, select "Remove".

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