Incident Submission

Incident Submission Form

Please fill out this form completely and accurately. Provide as much detail as possible to help us understand the incident. If you have any questions, please contact [Name/Department] at [Contact Information]
Reporter Details

Enter your first name only.

Enter your last name (surname or family name).

Example: yourname@example.com

Expected Format: 555-555-1234

Enter house number and street name. Example: 123 Water Street

City may auto-fill. Please verify.

state/Province may auto-fill. Please verify.


The country may auto-fill. Please verify.

Verify code (e.g., A1A 1A1 or 12345)

Affected Person: An individual reporting harm or property damage related to a specific event, action, or omission.
AFFECTED PERSON DETAILS

Select if the affected person is a City employee or not.

Enter first name only.

Enter last name (surname or family name).

Example: person@example.com

Expected Format: 555-555-1234

If known enter house number and street name. Example: 123 Water Street

City may auto-fill. Please verify

Province may auto-fill. Please verify.


Country may auto-fill. Please verify.

Verify code (e.g., A1A 1A1 or 12345)
ADDITIONAL INVOLVED PEOPLE

Select 'Yes' to enter details for one or more people involved (e.g. witness or lawyer).
ADDITIONAL INVOLVED PERSON DETAILS

Select if the affected person is a City employee or not

Select the person's role (e.g., Witness, Police)


Enter first name only.

Enter last name (surname or family name).

Example: person@example.com

Expected Format: 709-555-1234

Enter house number and street name. Example: 123 Water Street

City may auto-fill. Please verify.

Province may auto-fill. Please verify.


Country may auto-fill. Please verify.

Verify code (e.g., A1A 1A1 or 12345)
What Happened?

Provide a factual account: What happened, where, when, who was involved, and actions taken.

Select 'Yes' if an official report was made to the police.

This is the police report file number you would have received when reporting the incident to the authorities. If you do not have one it is okay to leave this field blank.

Select all that apply. Checking an option will reveal a section for more details.
Where did incident take place?

Search for and select the incident location address. Verify auto-filled details below.

City may auto-fill. Please verify.

state/province may auto-fill. Please verify.

Country may auto-fill. Please verify.

Verify code (e.g., A1A 1A1 or 12345)
When did the incident take place?

Format: MM/DD/YYYY. Cannot be a future date.




INJURY DETAILS

Factually describe the injury (type, body part, apparent severity). Avoid diagnosis.
Involved Vehicle/Equipment

Note: If you do not know the specific details of the vehicle, please use "N/A"

Select: Owned (City of Dublin) or Third Party (Private).

Enter the unit number (check door, dash, or plate).

Enter the make (e.g., Ford, Caterpillar).

Enter the model (e.g., F-150, 320).

Enter license plate number (e.g., AAA-123), if applicable.

Enter 4-digit year (e.g., 2023).


Select type (e.g., Pickup Truck, Bus).



Describe the damage (e.g., Dented fender on Unit 123, Broken window at main entrance).
To add another vehicle, please select "Add Another Vehicle" on the bottom-right portion of this section.
Property Damage

Select: Owned (City property), Third Party (Owned by others), Leased/Rented (Used by City).

Enter street number and name. Example: 123 Water Street

City may auto-fill. Please verify.

Province/State may auto-fill. Please verify.


Country may auto-fill. Please verify.


Describe the damage (e.g., Broken window at main entrance, Damaged park bench).
To add another property, please select "Add Another Property" on the bottom-right portion of this section.
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.

To add more than one attachment, select "Add Another Response". To remove the additional file upload option, select "Remove".
Declaration
This website is operated by the City of Dublin, Ohio, to receive and process insurance claims. To investigate and potentially administer your claim, the City collects certain personal information you provide, including your name, contact information, incident details, and supporting documentation. Do not submit information unrelated to your claim. The information collected here is the same as would be collected on an equivalent paper submission. The information you submit may be used and disclosed as permitted by law to verify your claim, prevent fraud, and process any benefits to you. If you would prefer to not provide this information via this website, you may submit your claim in paper form by contacting Ron Whittington, Risk Manager rwhittington@dublin.oh.us,  614-410-4411.

Consent

By submitting this form, you: (a) acknowledge that you have read and understand the above Disclaimer; (b) consent to the collection, use, and disclosure of the limited information you provide herein, for the purposes of investigating, adjudicating, and administering your insurance claim, including verification with relevant third parties as permitted by law; and (c) confirm that the information you provide is true and complete to the best of your knowledge. If you do not consent, do not submit your claim online.

Contact Information