California JPIA



.
Instructions
It is the responsibility of all City / Agency employees to immediately notify the Risk Manager upon receipt of knowledge or witnessing an occurrence or transaction from which a potential claim could result or in which the City / Agency could be liable. This information will give the CALIFORNIA JPIA the opportunity to perform pre-claim investigation of a significant incident. Prompt reporting is more important than having completed all of the information. Do not delay reporting while awaiting a piece of information. WHAT TO DO IN CASE OF A SIGNIFICANT INCIDENT MAKE NO COMMENT AS TO YOUR OPINION REGARDING CAUSE, FAULT OR LIABILITY! Notify the Risk Manager as soon as possible. Complete this form as follows: A. Enter the date and time of the incident. B. Identify and enter the name of the person(s) sustaining injury or a description of the property damages. C. Describe the exact location where the incident occurred. D. Briefly describe how the incident occurred. E. Briefly describe the damages or injuries observed. F. Describe weather conditions (was surface condition slippery, etc.). G. Obtain names, addresses and telephone numbers of persons involved or witnessing the incident. If the person involved makes claim overtures to you, advise that claims must be made with the City Clerk. If the person does not make claim overtures, do not volunteer information. If contacted by the Risk Manager or a CALIFORNIA JOINT POWERS INSURANCE AUTHORITY representative, furnish requested information as accurately and as quickly as possible. All persons, other than City personnel, seeking accident information should be referred to the City Clerk or to CARL WARREN & COMPANY, PO Box 25180, Santa Ana, CA 92799-5180, Telephone 714-740-7999 Ext. 140. Give other persons involved your name and City address. Please include newspaper clippings, police reports or other supplementary information you may have relating to this incident.
.
Significant Incident Report Online Form
Significant Incident Report Form (PDF version)
Significant Incident Report Form (MS Word Version)
..
These are PDF files, so you will need Acrobat Reader 4.0 (or later) to read them. If you do not have this program downloaded on your computer, you may download it free of charge from Adobe's website.
.