Name of Agency:
Name of Contact Person (name, phone and email):
Date of Accident (mm/dd/yy): Time (am/pm):
Submit Claim to:
Risk Management Division
310 Centennial Office Building
658 Cedar Street
St. Paul, MN. 55155
Phone 651-201-2592, Fax 651-297-7715
Weather Conditions
Description of Incident (how, where, why):
State of Minnesota
General Liability Incident Report
(To be completed by appropriate agency employees.
For cases not involving an automobile)
Extent of Damage to Property
Person(s) Injured (names, addresses and telephone number):
Witnesses (names, addresses and phone numbers):
Extent of Injury to Person(s):
Person completing the form name, phone, and email):
Emergency Reporting—After Hours and Weekends
Gallagher Bassett Phone (866) 489-5797, Fax (800) 748-6459
GB Client Number 004276
Additional Comments:
MnSCU- Inver Hills Community College
Thomas McCluney 651-450-3528