Will the city pay for pothole damage 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Information. Fill in your name, Social Security Number, and Employee ID as specified. Ensure accuracy for smooth processing.
3. Provide your contact details including email and address. If you have a new address, check the appropriate box and fill in the new information.
4. Select the Benefit Type Codes that apply to your claim. This helps categorize your expenses correctly.
5. For each expense incurred, enter the Description of Service along with the Starting and Ending Dates of Service. Be sure to include itemized amounts for reimbursement.
6. Review all entries for completeness and accuracy before signing the form at the bottom. Your signature certifies that all information is true and valid.
7. Once completed, fax your claim form along with supporting documentation to expedite processing.

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