Form Center

2. Date and Time of Loss*
   Date and Time of Loss

   Date and Time of Loss
3. Who was notified?

   1. Police
   2. Agency
   3. Others
5. Name of All Parties Involved:*
7. Description of Incident and Action Taken:*
9. Injury Information:
11. Type and extent of injury known:*
13. Name of injured Party:*
14. Phone Number*
16. Email Address*
18. Address*
20. City*
21. State*
22. Zip Code*
24. Name/Address of Attorney:
26. Damage to Property:
28. Description of Property & Damage:*

    (Age/Make/Model/Cost of Repairs)

30. Name of Owner:*
31. Phone Number*
33. Email Address*
35. Address*
37. City*
38. State*
39. Zip Code*
41. Witnesses:
43. Name
44. Email Address
46. Address
48. City
49. State
50. Zip Code
52. Phone Number
53. Fax Number
55. Name
56. Email Address
58. Address
60. City
61. State
62. Zip Code
64. Phone Number
65. Fax Number
67. Supporting Documents

    Please upload photos, proof of insurance, estimates, police report, etc.

69. **All general liability claims must be fully completed before submission for review.  The City will not accept incomplete forms. 

Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

* indicates a required field