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The "Report of Significant"
Incident form was designed to help reduce the cost of claims. Members
should use the form to provide the CALIFORNIA
JPIA with immediate notice of a significant incident so that we
can begin immediate investigation. This form should be completed and
returned as quickly as possible, regardless of whether claims have
The information which can be gathered while the scene is still fresh
can be invaluable in preparing the defense of possible claims. It
is much easier to locate witnesses immediately after the incident
rather than up to six months later when a claim may be filed. Prompt
reporting is more important than having completed all of the requested
Do not delay reporting while awaiting a piece of information. Please
complete the form below and click submit. If you would like to distribute
a hard copy of this form to your operating departments, simply open
the form using Adobe Acrobat.
If you have any questions or need further assistance, please call
our offices at (562) 467-8700.
In the unfortunate event that a significant incident occurs, please
be assured that we will do everything possible to reduce the losses
to your agency and the pool.