Claim Form
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Claim Form

Claim Form

Form for residents to submit a claim

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Instructions: If more information is required than a field allows for, please attach additional pages.

Name(Required)
Address(Required)

Incident Details

Location where incident occurred: (Address or nearest intersection, direction of travel, lane of travel [i.e. curb lane, left turn lane, middle lane]. Enclose map or diagram if needed.)
MM slash DD slash YYYY
Exact DATE incident occurred
Time(Required)
:
Exact TIME incident occurred

Claimant vehicle information IF vehicle involved in Incident

Type of City Vehicle Involved, if applicable

Indicate your estimated or actual cost to repair the damage. In the case of property damage, please provide 2 repair estimates. Attach additional pages if required, photos, invoices or other evidence.
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
Have you claimed, or will you be claiming, any compensation from an insurance provider?(Required)

Important

I fully understand that: 1. The information provided here is for the purpose of investigating and managing claims against the City and as such any information provided to the City may be used by the City in defending against a claim. 2. The City’s receipt of a Notice of Claim does not constitute acceptance of liability for any damage or loss sustained by the Claimant nor has the City provided any advice to the Claimant regarding the adequacy of this Notice. The undersigned hereby acknowledges that the City is not prevented by receipt of this Notice of Claim from arguing the adequacy hereof
MM slash DD slash YYYY
Consent(Required)

For a printable version please click the following (Link)

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