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2. This form is to be completed exclusively by a City of Hibbing employee or supervisor in the event of a liability-related incident. If you are not a City of Hibbing employee and wish to report a claim, please contact the City of Hibbing at 218-312-1575. 

   The form should be completed promptly following the incident, regardless of whether a claim is filed with the insurance carrier.

   Do not submit this claim directly to the insurance carrier.

4. Today's Date*
   Today's Date

   Today's Date
5. Date of Incident:*
   Date of Incident:

   Date of Incident:
6. First and Last Name of person completing this form:*
8. Name of employee involved in incident:
9. Employee job title:
10. Employee Department:
12. Supervisor Name:*
13. Supervisor Phone Number:*
15. Has the department supervisor been notified of the incident?*

    1. Yes
    2. No

    If no, please notify supervisor immediately.

17. Location/Address of Incident*
19. City
20. State
21. Zip Code
23. Detailed description of incident:*
25. Was a City vehicle, equipment, or property damaged in the incident?*

    1. Yes
    2. No
26. What type of City property was damaged?*
    -- Select One --VehicleEquipmentProperty
28. Description of damage to City vehicle, equipment or property:*
30. City Vehicle Model*
31. City Vehicle Make*
33. City Vehicle Year*
34. City Vehicle VIN*
36. Was any employee injured in this incident?*

    1. Yes
    2. No
37. Was a worker's compensation claim filed?*

    1. Yes
    2. No

    If no, file a worker's compensation claim by calling 844-847-8708.

39. Has this employee been involved in an accident/incident before?*

    1. Yes
    2. No
40. Date of previous incident:*
42. Description of previous employee incident:*
46. Did this incident involve personal injury to a non-employee or damage to non-City property?*

    1. Yes
    2. No
47. Check all that apply:*

    1. Damage to non-city property
    2. Personal injury (non employee)
49. Detailed description of non-city property damage.*
51. Detailed description of non-employee personal injury:*
53. Contact information for non-employee with damage to property or personal injury (if applicable):

    Questions will only generate in this section if the incident involved personal injury to a non-employee or damage to non-city property.

55. First Name*
56. Last Name*
57. Phone Number*
59. Address*
61. City
62. State
63. Zip Code
65. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) this incident form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
67. Electronic Signature
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field