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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'CLAIMANT INFORMATION' section. Enter your name, address, city, state, zip code, and phone numbers. Ensure all details are accurate for effective communication.
In the 'CLAIM INFORMATION' section, describe the occurrence or event that led to your claim. Include the date, time, and specific location of the incident.
Detail how the incident occurred and specify any actions taken by the City or its employees that caused damage or injury.
Provide a description of any injuries or damages incurred. If there were no injuries, simply state 'No Injury'.
For claims involving property damage, include information about the owner of the damaged property and any other individuals injured.
Complete the 'DAMAGES CLAIMED' section by entering amounts for current claims and estimated future costs. Attach supporting documents like bills or receipts.
If applicable, indicate court jurisdiction for claims over $10,000 and provide details about any law enforcement reports related to the incident.
Finally, review your entries for accuracy before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2008	4 Satisfied (27 Votes)

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