Ungated Landing Page 2

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Demo Accordion

Your Name(Required)

First

Last

Phone

Your email address(Required)

Enter Email

Confirm Email

Claim Contact Person

Name

First

Last

Contact Phone

Dept Supervisor

First

Last

Contact Email Address

City Department

Time & Place

Date of Loss or Accident

MM slash DD slash YYYY

Time of Loss or Accident

Hours
:

Minutes

AM/PM

Location of Loss or Accident

Street Address

Address Line 2

City

State

ZIP Code

Estimated Repair Costs

Auto and Equipment Info

Year Make Model VIN or Serial Number

Description of Damaged City Property or Auto

Describe Cause of LossAdditional Details

Robbery & Theft

Were Police notified?

Yes

No

Was Culprit Apprehended

Yes

No

Explain Explain Describe the situation below

Your Name*

First

Last
Phone
Your email address*

Enter Email

Confirm Email
Claim Contact Person
Contact Name

First

Last
Contact Phone
Dept Supervisor

First

Last
Contact Email Address
City Department
Time & Place
Date of Loss or Accident

MM slash DD slash YYYY
Time of Loss / Accident
:
Hours

Minutes

AM/PM
Location of Loss or Accident

Street Address

Address Line 2

City

State

ZIP Code
Weather Conditions
Your Automobile or Equipment
Year
Serial Number or VIN
Make & Model
License Plate Number
Does the city own the vehicle/equipment?
- Yes
- No
Driver Name

First

Last
Driver’s License Number
Driver’s License State

State
Driver Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Driver Home or Work Phone
Drivers Age
Is Driver a City Employee?
- Yes
- No
Please provide Name, Address & Telephone of Passengers in YOUR vehicle or equipment
For what purpose was the automobile being used at the of the accident?
Have the Police been notified?
- Yes
- No
Where may the vehicle/equipment be seen?
Case Number
Areas of Damage on Vehicle
Estimated Repair Costs
Traffic Citations Issued?
- Yes
- No
Witnesses & Injuries
Were there any witnesses?
- Yes
- No
Were there any injuries?
- Yes
- No
List the Names, Address & Telephone numbers of any Witnesses:
Driver’s Statement
Describe what happened:
Damage to Property of Others
Owner Name

First

Last
Owner Telephone
Owner Address

Street Address

Address Line 2

City

State

ZIP Code
Other Driver’s Name

First

Last
Other Driver’s License Number
Other Driver’s Address

Street Address

Address Line 2

City

State

ZIP Code
Other Driver’s License State

State
List Damage
Other Vehicle Year, Make, Model
Other Plate Number
Other Plate State

State
Other Insurance Policy Number
Insurance Carrier Name
Additional Property Damage or Vehicles
Please describe additional property or vehicle damage
List the Names, Address, Telephone Numbers & Nature of Injury of anyone injured as a result of this auto accident:

Your Name

First

Last

Phone

Your email address(Required)

Enter Email

Confirm Email

Claim Contact Person

Contact Name

First

Last

Contact Phone

Contact Email(Required)

Enter Email

Confirm Email

Dept Supervisor

First

Last

Department

Time & Place of Accident or Loss

Date

MM slash DD slash YYYY

Time

Hours
:

Minutes

AM/PM

Location

Street Address

Address Line 2

City

State

ZIP Code

Estimated Repair Costs

Building and / or Contents

Decribe Cause of LossAdditional Details

Boiler & Machinery

Describe Details of Loss

Robbery & Theft

Were Police notified?

Yes

No

Explain

Was Culprit Apprehended

Yes

No

Explain Decribe the situation belowPhoneThis field is for validation purposes and should be left unchanged.

Google

Employee Information

City Department(Required)

Employee Name(Required)

First

Last

Employee Date of Birth

MM slash DD slash YYYY
Employee Phone(Required)Employee Email

Contact Tracing

Did you have close contact with someone that tested positive?(Required)

Yes

No
Close contact is defined by being within 6 feet of another individual for more than 15 minutes and who has tested positive for COVID-19.

If “YES,” what is the date of your last exposure to them?(Required)

MM slash DD slash YYYY

COVID-19 Exposure

When did symptoms start?(Required)

MM slash DD slash YYYY
When was the last day you were physically at work?(Required)

MM slash DD slash YYYY

Vaccinated?(Required)

Yes

No

Date of Last Shot(Required)

MM slash DD slash YYYY

Have you received your BOOSTER shot?(Required)

Yes

No

If “YES” above, what date?

MM slash DD slash YYYY
Test Results(Required)

List of Close Contacts:

For COVID-19, a close contact is anyone who was within 6 feet of an infected person for a total of 15 minutes or more within a 24-hour period. The infection period is two days before the onset of symptoms, or from the date of test, whichever comes first.

If you have tested POSITIVE for COVID-19:

Have you had 2 negative ANTIGEN tests performed at least 24 hours apart, beginning no earlier than day 4?

Yes

No

Date of Test 1 (If applicable

MM slash DD slash YYYY
Date of Test 2 (If applicable

MM slash DD slash YYYY

Are you asymptomatic?

Yes

No

If you had symptoms, have they subsided?

Yes

No

Have you had NO fever for at least 24 hours WITHOUT the use of medicine that helps reduce fevers?

Yes

No

Your Name*

First

Last
Phone
Your email address*

Enter Email

Confirm Email
Claim Contact Person
Name

First

Last
Contact Phone
Dept Supervisor

First

Last
Contact Email Address
City Department
Time & Place
Date of Loss or Accident

MM slash DD slash YYYY
Time of Loss or Accident
:
Hours

Minutes

AM/PM
Location of Loss or Accident

Street Address

Address Line 2

City

State

ZIP Code
Officials Called to Scene
- Fire
- Ambulance
- Police
From which locale?
Injured Party – Property Damage
Name

First

Last
Phone
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Claimant Age
Extent of Damage
Location of Property

Street Address

Address Line 2

City

State

ZIP Code
Injured Party – Bodily Injury
Name

First

Last
Phone
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Occupation
Claimant Age
Describe Extent of Injury:
Summary
Description of Claim (General Liability). If involving Contractor’s Equipment, please include Make, Model & Year of Vehicle.
Witnesses & Injuries
Were there any witnesses?
- Yes
- No
List the Names, Address & Telephone numbers of any witnesses:
CommentsThis field is for validation purposes and should be left unchanged.

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Location

Street Address

Address Line 2

City

State

ZIP Code

Department

Employee Name

First

Last

Employee PhoneEmployee Number Employee Job Title Employee DOB

MM slash DD slash YYYY
Hire Date

MM slash DD slash YYYY

Email(Required)

Enter Email

Confirm Email

Is Employee Married?

Yes

No

Employee’s Gender

Male

Female

Description of Incident

Incident Details

Date

MM slash DD slash YYYY
Witness(es)

Time

Hours
:

Minutes

AM/PM

Employee Lost Time to Injury

Yes

No

Date Reported

MM slash DD slash YYYY

First Aid Given

Yes

No

Incident Location

Street Address

Address Line 2

City

State

ZIP Code

On Employer Premise?

Yes

No

Parts of Body InjuredIf other, please describe:Nature of InjuryIf other, please describe:

City of Burlington

Summaries and Analytics

Workers’ Compensation Seminar Schedule 2022

2022-2023 Mod Projection

City of Burlington Claim Review

Focus Plan 2021-2022 COB

LORAN – City of Burlington Annual Trending 2021

Loss Prevention Safety Training 2022 Jan-April

Focus Plan 2021-2022 COB

LORAN – City of Burlington Annual Trending 2021

Loss Prevention Safety Training 2022 Jan-April

Demo Accordion

Claim Contact Person

Time & Place

Auto and Equipment Info

Description of Damaged City Property or Auto

Robbery & Theft

Claim Contact Person

Time & Place

Your Automobile or Equipment

Witnesses & Injuries

Driver’s Statement

Damage to Property of Others

Additional Property Damage or Vehicles

Claim Contact Person

Time & Place of Accident or Loss

Building and / or Contents

Boiler & Machinery

Robbery & Theft

Employee Information

Contact Tracing

COVID-19 Exposure

If you have tested POSITIVE for COVID-19:

Claim Contact Person

Time & Place

Officials Called to Scene

Injured Party – Property Damage

Injured Party – Bodily Injury

Summary

Witnesses & Injuries

Incident Details

Safety Training

Upcoming Webinars

Submit a Claim

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