HomeMy WebLinkAboutCORRESPONDENCE - GENERAL CORRESPONDENCE - FORMS FOR RISK®City of Fort Collins / Poudre Fire Authority bhkik
City of Fort Collins CITIZEN CLAIM FORM
NOTICE REQUIRED: Any person claiming to have suffered an injury by a public entity or by an employee thereof, while in the
course of their employment, shall file a written notice as provided by COLORADO REVISED STATUTES, Section 24-10-109,
within one hundred eighty (180) days after the date of the discovery of the injury.
NAME AND ADDRESS OF THE CLAIMANT AND ATTORNEY IF ANY:
Claimant: Name: Phone:
Address:
Street City Zip
Attorney: Name: Phone:
Address:
Street City Zip
Concise statement of the basis of the claim:
Date of the Incident: Time:
Month Day Year
Location:
No. & Street city
Brief description of the incident:
Name and address of any public employee involved, if known:
Name: Address:
BODILY INJURY CLAIMS:
Name of Injured:
Nature of the Injury:
MOTOR VEHICLE CLAIMS:
Citizen Vehicle: Year Make
Driver's Name:
Driver's License No.
Describe Damage:
City Vehicle: Driver's Name:
Police Report No.
PROPERTY DAMAGE:
Type of Property Damaged (ie: building, equipment, etc.):
Estimated Damage- $
Phone (Home)
Estimated Damage: $
Model
Phone (Home)_
Insurance Company
Department:
Estimated Damage: $
Zip
(Work)
License #
(Work)
a.m./p.m.
Signature: Date:
The acceptance of this claim report does not signify an admission of liability by the City of Fort Collins or Poudre Fire Authority. Mail
completed report and documentation to:
CITY OF FORT COLLINS
RISK MANAGEMENT
P.O. BOX 580
FORT COLLINS, COLORADO 80522-0580 Blue - Risk Management
REV 10/05
Pink - CityAttorney's Office
CITY OF FORT COLLINS - INCIDENT REPORT
(DO NOT USE FOR WORK RELATED INJURIES/EXPOSURES) ,
CiN of Fosf Collins
This form is needed when potential damage has been caused to a citizen's property/vehicle or bodily injury, OR damage to City
vehicle or City property has occurred. Employee involved should complete form and supervisor should sign. The report should he
submitted to Risk Management within four days of the incident.
DATE OF INCIDENT TIME am / pm
Month Day Year
LOCATION
Number and Street City State
COMPLETE DESCRIPTION OF INCIDENT:
POLICE REPORT NUMBER:
CABLE CUTS: ❑ LOCATES GOOD ❑ NO LOCATES ❑ MIS -LOCATED
❑ VANDALISM ❑ THEFT ❑ STORM RELATED ❑ UNKNOWN CAUSE ❑ HIT & RUN
❑ OTHER:
NAME OF CITIZEN/COMPANY INVOLVED
MAILING ADDRESS
PHONENUMBER
FOR RISK
MANAGEMENT
USE
Type of Incident
Date of Incident
incident/Claim Number
Date Logged
Code I CUO
Claim Value $
Department $$
Loss Fund $$
CHECK AND COMPLETE ALL SECTIONS THAT APPLY
POTENTIAL CITIZEN CLAIM: PropertyNehicle Damage and Bodily Injury/Exposure
DESCRIBE DAMAGE TO CITIZEN'S PROPERTYNEHICLE OR BODILY INJURY:
VEHICLE DAMAGE
CITY UNIT NO. YEAR MAKE MODEL
DRIVER'S NAME ❑ OCCUPIED ❑ UNOCCUPIED
(Please Print)
DESCRIBE DAMAGE TO CITY VEHICLE:
IS THIS A COMMERCIAL MOTOR VEHICLE? ❑ YES ❑ NO
TO BE COMPLETED BY FLEET SERVICES:
DAMAGE $ DISPOSITION: ❑ REPAIRED ❑ NO DAMAGE ❑ TOTALED ❑ OTHER
COMPLETED BY DATE
CITY PROPERTY DAMAGE: (Building, equipment, computer, cell phone, etc.)
DESCRIBE DAMAGE TO CITY PROPERTY:
DAMAGE $ DISPOSITION: ❑ REPAIRED ❑ NO DAMAGE ❑ TOTALED ❑ OTHER
EMPLOYEE COMPLETING REPORT:
NAME DEPT-/DIVISION
SIGNATURE
SUPERVISOR'S SIGNATURE:
DATE
WORK PHONE NO.
WORK PHONE NO.
DATE
ANY QUESTIONS PLEASE CALL RISK MANAGEMENT 221-6708
(DO NOT SEPARATE - RETURN ALL COPIES TO RISK MANAGEMENT)
Distribution: PINK and WHITE - Risk Management BLUE - Reporting Department YELLOW - Fleet Services
WORKERS' COMPENSATION INJURY/EXPOSURE REPORT
This form is needed when an employee is injured while in the course of employment.
clivo[Fencetun, Employee should complete Part I and Part 11 in full; Supervisor should complete and sign Part III.
If employee. is not able to complete form, supervisor should do so. Submit to Risk Management within four days of injury.
PART I — EMPLOYEE
Employee's Name (First, Middle, Last)
Social Security Number
Sex
Employee Home Telephone No.
CI Male
❑ Female
Employee's Street Address
City
State
Zip Code
Occupation
Age
Birthdate
Dependents
How long has employee
Job assigned when injured/exposed?
Length of experience
worked for this employer?
at this assignment?
Mo. I Day J Yr.
❑ Yes ❑ No
Year of Education Completed (circle one)
Race
6 7 8 9 10 11 12 13 14 15 16 17 18
19 20
❑ Asian ❑ Black ❑ Hispanic ❑ White ❑ Do Not Wish To Answer
DO NOT
WRITE IN
THIS COLUMN
PART 11 — INJURY INFORMATION
Injury Date
What happened to cause this Injury or Illness? Describe employee's activities when injury or illness occurred with details of how event or exposure occurred
(include name(s) of other individuals Involved, tools, machinery, objects, vapors, chemicals, radiations, unnatural motions of employee, etc.)
Mo. Day Yr.
Also, specify the Items which directly Injured the employee and caused the accident or Illness.
.
Injury Time
❑ a.m.
❑ P.M.
Please list any safety concerns:
Injury Description (State exactly the part of the body affected and the name of Injury or Illness)
Names of Witnesses
Name of Employer Representative Notified
Place of Accident/Exposure
Treatment received: ❑ First Aid ❑ Emergency Room ❑ Doctor ❑ None
Name and Address of Treating Doctor
It Is unlawful to knowingly provide false, Incomplete, or misleading facts or Information to an Insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may Include Imprisonment, fines, denial of Insurance, and civil damages. Any Insurance company
or agent of an Insurance company who knowingly provides false, Incomplete or misleading facts or Information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to settlement or award payable from Insurance
proceeds shall be reported to the Colorado Dlvislon of Insurance Within the Department of Regulatory Agencies.
You are hereby notified that If a child support obligation Is owed, compensation benefits may be attached and payment of the child support
obligation may be withheld and forwarded to the obligee pursuant to sections 8.42.124 and 26-13.122(4), C.R.S.
Employee Signature
Date
PART III - SUPERVISOR MUST
COMPLETE THIS SECTION OF THE REPORT
Employee's Scheduled
Hrs. Per Day
Days Per Week
Last Day Worked
Date Employer Notified
Modified Work Available 11 Applicable
Work Week When Injured
Mo. Day Yr,
Mo. Day Yr.
❑ Yes ❑ No
I
If No, why?
Employee's Usual
Hrs. Per Day
Days Per Week
Mo. Day Yr,
Did injury cause death?
ate of death
Work Schedule
❑ Date Returned to Work
O Yes ❑ No
Mo. Day Yr.
❑ Estimated Date of Return
Please list any safety concerns:
Did Injury occur because of: ❑ Intoxication ❑ Failure to use Safety Devices ❑ Failure to Obey Rules O Not Applicable
Date of Report
Work Phone
Supervisor's Signature
Print Name
DO NOT SEPARATE / RETURN ALL COPIES TO RISK MANAGEMENT
Green - Risk Management Yellow - Department Blue - Employee Pink - Workers' Compensation Administrator
09104
CITY OF FORT COLLINS
AND
POUDRE FIRE AUTHORITY
SAFETY GLASS AUTHORIZATION
(See reverse side of form for Safety Eye -Glass Policy and Procedure)
EYE CENTER OPTICAL EYECARE ASSOCIATES PC COLORADO VISION CENTER
1725 EAST PROSPECT RD 1304 SOUTH SHIELDS ST 1027 WEST HORSETOOTH RD
970-493-0400 970-221-4812 970-206-0100
THIS IS TO AUTHORIZE:
THE PURCHASE OF, ONE PAIR OR TWO PAIR, PRESCRIPTION SAFETY GLASSES FOR:
Full-time employees are eligible for two pair of prescription safety glasses every two years.
Seasonal/Hourly/Contractual employees are eligible for one pair of prescription safety glasses each year.
EMPLOYEE STATUS: FULL-TIME SEASONAL/HOURLY/CONTRACTUAL
REPAIR OR REPLACEMENT OF PRESCRIPTION SAFETY GLASSES FOR:
PLANO SAFETY GLASSES FOR:
NAME
EMPLOYEE JOB TITLE
DEPARTMENT
NOTE: 1) EYE PRESCRIPTION NEEDS TO BE WRITTEN WITHIN THE LAST 90 DAYS.
2) EMPLOYEE PROVIDES PRESCRIPTION FOR SAFETY GLASSES.
31 AUTHORIZATION FOR PURCHASE OF SAFETY GLASSES DOES NOT INCLUDE PRESCRIPTION.
YES NO SIDE SHIELDS ARE REQUIRED FOR THIS PRESCRIPTION.
WORK -RELATED HAZARDS TO JUSTIFY SAFETY GLASSES INCLUDE:
11
(SUPERVISOR'S SIGNATU
(AUTHORIZED SIGNATURE from RISK MANAGEMENT)
Rev. 04/01 /05
(DATE)
(DATE)
SAFETY EYE -GLASS POLICY AND PROCEDURE
PURPOSE:
The purpose of this City policy is to require the use of eye protection where there is reasonable probability that an injury
can be prevented by use of such equipment. This regulation shall apply to such operations, processes, or work which
involve a hazard to the eyes from flying objects or particles, sprays or splashes, or hot or corrosive materials or chemicals.
RESPONSIBILITY:
Each City employee will be responsible for adhering to this policy and these procedures. Supervisors are responsible for
educating employees on these procedures and assuring that proper eye protection is available and worn.
POLICY AND PROCEDURE:
A. AN employees shall be provided with and required to wear proper eye protection when exposed to an operation or
area where eye hazards normally exist. Some examples are listed below:
1. Arc or gas welding, brazing, cutting.
2. Machining or woodwork which causes flying particles.
3. Use of pneumatic tools or power -actuated tools.
4. Splashing from molten metals or substances, hot or corrosive liquids, acids and caustics.
5. Use of power lawn mowers and tree and grass trimmers.
6. Sledging, chipping, hammering, scaling, drilling, grinding, sanding, etc.
7. Presence of danger of an electrical arc.
8. Performance of primary switching operations, both overhead and underground.
9. Operation of open equipment, tractors, graders, front-end loaders.
10. Firearms training or practice.
B. Non-prescription eye -protective devices are purchased and distributed by each department.
C. Employees provided with eye protection are responsible for its maintenance and proper use. If said equipment is
damaged or lost through misuse or carelessness, the employee responsible may be charged with the replacement
cost.
D. Eye protectors that are worn by more than one worker must be maintained in a clean, sanitary condition.
E. The City will pay the actual cost of prescription industrial -safety eye wear for those employees required to reauladv
wear safety eye protection on the job by their department.
1. The prescription protective eye wear must be purchased through a vendor specified by the Risk
Management Division.
2. Risk Management shall purchase two pair (clear or tinted) of prescription safety eye wear per 24 months
for full-time employees. Seasonal/hourly/contractual employees will be eligible for one pair of prescription
safety eye wear per 12 months. Risk Management will pay for the cost of prescription safety glasses with
the exception of:
a. transition lenses
b. mirror finish
3. If an employee's prescription safety glasses are broken or damaged as a result of an industrial accident,
through no fault of the employee, Risk Management will repair or replace them.
4. Based on the job being performed, it may be necessary to wear additional protection over the prescription
safety glasses.
Rev. 03/01 /98