City of Welland Claim/Incident Reporting Form

Reporter Details

"Reporter" is the person filling out this form

Are you reporting this incident/claim on behalf of someone else?

Involvement Type

First Name

Last Name

Gender

Birthdate

Home Phone

Phone

Mobile Phone

Business Fax

Badge Number

Title

Contact Description

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Did this person sustain an Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Description of Personal Injuries

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Health care provider's name

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

Claimant Claim Number

Claimant Insurance Company

Employee Doing Regular Job?

Lost Time?

Required Hospital Time

Last Worked Date

Treated in an Emergency Room?

Hospitalized Overnight as an In-Patient?

First Disability Date

Return to Work Date

First Full Workday Lost After Injury

Return to Work Restricted?

Hospital Name

Hospital Street Address

Hospital City

Hospital State/Province

Hospital Zip/Postal Code

NCCI Class Code

NCCI Injury Code

NCCI Loss CovCode

NCCI Type Code

Lost Days

Restricted Days

Time Workday Began

A/P

AM/PM

OSHA Record?

OSHA Classification

OSHA Injury Type

OSHA Accident Location

OSHA Injury Description

Incident/Claim Information

Incident Type

Incident Type Other

Incident Date/Time

A/P

AM/PM

Incident Address

Incident City

Incident State/Province

Incident Country

Incident Description

Incident Cost Incurred

Cause

Source

Litigation?

Record Type ID

Owned/Leased Vehicle Involved?

Owned/Leased Property Involved?

3rd Party Vehicle Involved?

3rd Party Property Involved?

Department

Are repairs/maintenance required?

Construction in Area?

Construction Information

Location of Construction

Type of Construction

Name of Construction Company If Known

Do you recall if there were any construction signs, traffic cones, etc. ?

Litigation Details

Legal Representation

Statement of Claim

Statement of Claim Number

State/Province of Jurisdiction

Legal Disclosure Date

Legal Representation Date

Plaintiff Attorney Disclosure Date

Plaintiff Attorney Representation Date

In Suit?

Suit/Case Name

Suit Filed Date

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, witness to the Incident, lawyer, police officer, employees, etc.)

Do you wish to add "Involved Persons" to this report?

Involvement Type

First Name

Last Name

Birthdate

Gender

Home Phone

Phone

Mobile Phone

Business Fax

Title

Adjuster Number

Badge Number

Contact Description

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Sustained Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Description of Personal Injuries

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Health care provider's name

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

Claimant Claim Number

Claimant Insurance Company

Employee Doing Regular Job?

Lost Time?

Required Hospital Time

Last Worked Date

Treated in an Emergency Room?

Hospitalized Overnight as an In-Patient?

First Disability Date

Return to Work Date

First Full Workday Lost After Injury

Return to Work Restricted?

Hospital Name

Hospital Street Address

Hospital City

Hospital State/Province

Hospital Zip/Postal Code

NCCI Class Code

NCCI Injury Code

NCCI Loss CovCode

NCCI Type Code

Lost Days

Restricted Days

Time Workday Began

A/P

AM/PM

OSHA Record?

OSHA Classification

OSHA Injury Type

OSHA Accident Location

OSHA Injury Description

To add another involved person, please select "Add another response" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore.

Follow-Up and Corrective Actions

What was the person doing?

Follow Up Completed By:

How can a similar occurrence be prevented?

Need Assistance from safety partner?:

Lessons learned to prevent injuries:

Action Taken:

Safety Partner Assigned

Additional Notes

Areas for Corrective Action

Sub Area

Priority

Involved Vehicle (Internal)

Vehicle VIN

Description of Damages to Vehicle

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

Involved Property (Internal)

Property Name

Description of Damages to Property

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

3rd Party Involved Vehicle

Vehicle Type

3rd Party Vehicle Colour

3rd Party Vehicle Make

3rd Party Vehicle Model

3rd Party Vehicle Year

3rd Party Vehicle License Plate Number

3rd Party Vehicle VIN

Description of Damages

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

3rd Party Involved Property

3rd Party Property Address

3rd Party Property City

3rd Party Property State/Province

3rd Party Property Country

3rd Party Property Zip/Postal Code

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".

Declaration

The information provided herein is true. I understand that submitting false statements and/or

documentation is a form of fraud and is illegal. I acknowledge that fraudulent claims cost taxpayers, and that claims that are determined to be made fraudulently will be prosecuted to the full extent of the law.

I hereby give consent to the City of Welland to collect, use or disclose my information that is necessary and reasonable for the purposes of processing my claim.

I accept that the City will disclose my personal information to the City’s insurance adjuster and/or to those involved in the resulting claim resolution, including but not limited to lawyers, or third parties that are found responsible for losses claimed.

I have read, acknowledge and understand the consequences and agree with the statement above

I agree

NOTE: If you do not agree, the City of Welland is unable to accept your on-line form as notice to the City about your claim.